Este día les voy a hablar de neuralgia postherpetica.
Nos vemos.
domingo, 15 de julio de 2012
sábado, 9 de junio de 2012
Martes 12 de junio
Un estudio reciente muestra que cerca del 40% de los pacientes que se someten a una cirugía tienen dolor a los 3 meses del postoperatorio. Cerca del 20 % de estos lo continúan presentando hasta un año después.
Es eso cierto ? En que cirugías se presenta este fenómeno ? Cuales son los factores de riesgo ?
Cual es mecanismo fisiopatológico que explica este fenómeno ?
Es eso cierto ? En que cirugías se presenta este fenómeno ? Cuales son los factores de riesgo ?
Cual es mecanismo fisiopatológico que explica este fenómeno ?
lunes, 4 de junio de 2012
lunes, 21 de mayo de 2012
viernes, 18 de mayo de 2012
Martes 22 de Mayo 2012
Jairo tiene 45 años, es hipertenso tiene una enfermedad coronaria y una arritmia por lo que toma amiodarona. Desde hace 10 años tiene dolor crónico posterior a un accidente automovilístico que le lesionó el miembro inferior. Tiene un dolor neuropático y somático que responde aceptablemente al tratamiento con antidepresivos, anticonvulsivantes y opioides. El único efecto secundario que tiene consiste en nauseas que se controlan con ondasetrón. Nunca ha abusado de los opioides.Actualmente usa metadona 120mg por día, carbamazepina 300mg al día, amitriptilina 75mg en las noches. Refiere que los bloqueos no le han servido y que con este manejo es funcional pudiendo trabajar como bibliotecólogo.
En vista de que hay nuevos medicamentos anticonvulsivantes y antidepresivos disponibles, considera apropiado proponerle un cambio en el manejo analgésico ?
En vista de que hay nuevos medicamentos anticonvulsivantes y antidepresivos disponibles, considera apropiado proponerle un cambio en el manejo analgésico ?
sábado, 12 de mayo de 2012
Martes 15 de Mayo
Marco tiene 34 años y es sometido a la corrección de un hallux valgus bilateral. Su Anestesiólogo le decide realizar un bloqueo del cuello del pie. Para eso utiliza una mezcla de bupivacaina al 0,5 % y lidocaina al 2%. Utilizo en total 30ml. La cirugía empieza sin complicaciones.
Al Anestesiologo le llama la atención que Marco esta muy somnoliento durante la cirugía con tan solo 2 mg de midazolam y al preguntarle niega tener sabor metálico.
Marco estaba hipertenso y taquicárdico aunque no tenía dolor.
Marco ahora tiene una TA de 70/30
Tiene extrasístoles ventriculares.
1. Cual es el problema
2. Como se previene ?
3. Quien esta en riesgo de presentarlo
4. Como se maneja.
Al Anestesiologo le llama la atención que Marco esta muy somnoliento durante la cirugía con tan solo 2 mg de midazolam y al preguntarle niega tener sabor metálico.
Marco estaba hipertenso y taquicárdico aunque no tenía dolor.
Marco ahora tiene una TA de 70/30
Tiene extrasístoles ventriculares.
1. Cual es el problema
2. Como se previene ?
3. Quien esta en riesgo de presentarlo
4. Como se maneja.
domingo, 6 de mayo de 2012
8 de Mayo
Andrés tiene 22 años y tiene una fractura de tibia. Sofía es ciega y tiene dolor abdominal. Raquel es sorda y sufre de cefaleas. Margarita es ciega, sorda y muda y tiene una hernia discal. Sebastián tiene un trauma cráneo encefálico y tiene un Glasgow de 4. El hijo de María es prematuro y el de Soledad tiene 1 año. Nicolás tiene 5 años.
Si a todas estas personas queremos evaluarle el dolor, que hacemos. ?
Si a todas estas personas queremos evaluarle el dolor, que hacemos. ?
martes, 17 de abril de 2012
De medscape- Opioid Rotation Practices Linked to Fatalities
Opioid Rotation Practices Linked to Fatalities
Pauline Anderson
April 5, 2012 — Opioid rotation — switching from one opioid drug or route of administration to another to improve the outcome — is largely to blame for the growing number of unintentional deaths related to opioids, a new review suggests.
The review cites evidence of a link between opioid-related deaths and common opioid rotation practices, including the use of dose-conversion ratios published in equianalgesic tables.
Opioid rotation is flawed, said study coauthor Lynn R. Webster, MD, president elect of the American Academy of Pain Medicine and medical director and founder of Lifetree Clinical Research, Salt Lake City, Utah. Although using conversion tables is harmless in most cases, "this is an area where the harm has such devastating consequences — death — that we cannot accept even a 1% error," said Dr. Webster.
Along with his coauthor, Perry G. Fine, MD, Pain Research Center and Pain Management Center, University of Utah, Salt Lake City, Dr. Webster reviewed the literature and found several case reports of opioid-related deaths or "near misses."
The review was published online March 28 in Pain Medicine, the official journal of the American Academy of Pain Medicine.
In an accompanying article published at the same time in the same journal, Dr. Webster and Dr. Fine suggest a slower and potentially safer method for switching opioids.
Painkiller Overdoses
Almost 15,000 people die every year as a result of overdoses involving prescription painkillers, with that number exceeding deaths from heroine and cocaine combined, according to a Centers for Disease Control and Prevention report. The US Food and Drug Administration (FDA) found that opioids, including oxycodone, fentanyl, morphine, methadone, and acetaminophen/hydrocodone, accounted for 5 of the 15 drugs most frequently named in fatal outcomes.
According to the new review, most proposed protocols for opioid rotation involve the use of equianalgesic dosing tables to convert the dose of the original opioid to a putative equivalent dose of morphine. That dose is then converted to that for the new opioid, with a safety margin incorporated.
One of the problems is that the most widely accepted guideline for opioid rotation was developed many years ago. At the time, experts believed that the relative strength of one opioid compared with that of another in the chronic state would be the same as that in the acute state, said Dr. Webster. "In other words, we didn't take into account that people would develop a tolerance, and certainly until just recently, we never knew about the genetic issues."
Not only did most studies use a single dose or a limited range of doses, they also investigated only a specific route. Thus, the findings aren't generalizable to other routes. Further, the studies didn't account for responses based on ethnicity, advanced age, concomitant medication use, or comorbid conditions.
"The key issue is that every human being has a different sensitivity to every different opioid molecule," said Dr. Webster. "So the way you respond to morphine will be different to the way that I respond to morphine, even in the acute state."
The rotation protocol has never been formally validated for safety or efficacy, added Dr. Webster. "There has never been an attempt to determine what is an equal analgesic of 1 opioid over another for chronic use — for example, after someone has been on a drug for 6 months or a year or 2. There is no research that has demonstrated consistently, across the board, that these tables have any validity."
Relying on tables derived from single-dose studies is especially problematic with repeated dosing of methadone. The authors noted the FDA's public health advisory on deaths and life-threatening changes in breathing and heart rate in patients newly started on methadone.
Although prescribing a new pain reliever might be necessary because of loss of effectiveness or side effects, in many cases the switch is called for because an insurer no longer covers a particular drug, said Dr. Webster. "So doctors have been forced to move to less costly drugs, and the least costly is usually methadone."
Gambling With Life?
Contributing to the problem is that published equianalgesic tables have inconsistent and variable conversion ratios. In addition, dose conversion guidelines found in package inserts for opioids, particularly the newer extended-release opioids, are inconsistent and potentially dangerous, said Dr. Webster.
He used the example of hydromorphone (Exalgo, Mallinckrodt/Covidien); the language of the insert is such that the conversion would result in 1 of 3 options, he said: an underestimate of the amount of extended-release hydromorphone necessary for adequate analgesia, an overestimate of the necessary amount that could increase the risk for overdose, or a dose within a reasonable window.
This, said Dr. Webster, boils down to "guessing" or "gambling" on the part of the clinician. "When we're dealing with a life, we should not be gambling."
Prescribing competence is "shockingly inadequate," said the authors. Errors can stem from inadequate education, lack of attention to detail, and calculation errors.
Confusion can also contribute to the problem. A survey of 406 non–pain specialist physicians found that 59% had difficulty calculating opioid dosages when rotating. When asked to convert a daily dose of 60 mg oxycodone to the dose for a fentanyl patch, 41% of clinical specialists, 28% of general practitioners, and 17% of geriatric care physicians said they "don't know" how to do that.
Physicians may be lulled into believing that conversion tables are safe and appropriate. "We like to have things structured in medicine," said Dr. Webster. "These tables were established to some degree to provide some security and safety and guidance toward rotating, but the irony is that they've actually made it unsafe."
Research suggests that 50% to 80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.
In their second report, a clinical case also published in Pain Medicine, Dr. Webster and Dr. Fine suggest an alternative to using opioid-rotation tables.
The best approach, they suggest, is to decrease the first drug by 25% to 30% per week while introducing the new drug at a dose that would be given to an opioid-naive patient, increasing the dose according to the clinical response, said Dr. Webster. "In many instances, it may take 3 to 4 weeks to rotate from one opioid to another," he said.
If patients are experiencing pain during the switch, physicians should give an immediate-release opioid to help "bridge" inadequate dosing.
He cautioned that some patients may be sensitive to the new drug. "A new molecule may be highly effective at a very low dose."
Hold Next Dose
Seddon Savage, MD, medical director, Chronic Pain and Addiction Program, Silver Hill Hospital, New Canaan, Connecticut, and president of the American Pain Society, agrees with this slow rotation protocol.
She added that patients should be told that if they feel sedated they should hold their next opioid dose and call their physician.
Dr. Savage commented that the review paper does a good job of pointing out and documenting the problems related to opioid rotation and of making physicians more aware of the limitations of conversion tables.
"One of the points that the authors make is that there is a lot of variability in response to different opioids. If you take these opioid conversion tables as gospel, apply them indiscriminately to all people, and just do a mathematical conversion, you will end up with some people for whom the conversion aren't appropriate."
Pauline Anderson
April 5, 2012 — Opioid rotation — switching from one opioid drug or route of administration to another to improve the outcome — is largely to blame for the growing number of unintentional deaths related to opioids, a new review suggests.
The review cites evidence of a link between opioid-related deaths and common opioid rotation practices, including the use of dose-conversion ratios published in equianalgesic tables.
Opioid rotation is flawed, said study coauthor Lynn R. Webster, MD, president elect of the American Academy of Pain Medicine and medical director and founder of Lifetree Clinical Research, Salt Lake City, Utah. Although using conversion tables is harmless in most cases, "this is an area where the harm has such devastating consequences — death — that we cannot accept even a 1% error," said Dr. Webster.
Along with his coauthor, Perry G. Fine, MD, Pain Research Center and Pain Management Center, University of Utah, Salt Lake City, Dr. Webster reviewed the literature and found several case reports of opioid-related deaths or "near misses."
The review was published online March 28 in Pain Medicine, the official journal of the American Academy of Pain Medicine.
In an accompanying article published at the same time in the same journal, Dr. Webster and Dr. Fine suggest a slower and potentially safer method for switching opioids.
Painkiller Overdoses
Almost 15,000 people die every year as a result of overdoses involving prescription painkillers, with that number exceeding deaths from heroine and cocaine combined, according to a Centers for Disease Control and Prevention report. The US Food and Drug Administration (FDA) found that opioids, including oxycodone, fentanyl, morphine, methadone, and acetaminophen/hydrocodone, accounted for 5 of the 15 drugs most frequently named in fatal outcomes.
According to the new review, most proposed protocols for opioid rotation involve the use of equianalgesic dosing tables to convert the dose of the original opioid to a putative equivalent dose of morphine. That dose is then converted to that for the new opioid, with a safety margin incorporated.
One of the problems is that the most widely accepted guideline for opioid rotation was developed many years ago. At the time, experts believed that the relative strength of one opioid compared with that of another in the chronic state would be the same as that in the acute state, said Dr. Webster. "In other words, we didn't take into account that people would develop a tolerance, and certainly until just recently, we never knew about the genetic issues."
Not only did most studies use a single dose or a limited range of doses, they also investigated only a specific route. Thus, the findings aren't generalizable to other routes. Further, the studies didn't account for responses based on ethnicity, advanced age, concomitant medication use, or comorbid conditions.
"The key issue is that every human being has a different sensitivity to every different opioid molecule," said Dr. Webster. "So the way you respond to morphine will be different to the way that I respond to morphine, even in the acute state."
The rotation protocol has never been formally validated for safety or efficacy, added Dr. Webster. "There has never been an attempt to determine what is an equal analgesic of 1 opioid over another for chronic use — for example, after someone has been on a drug for 6 months or a year or 2. There is no research that has demonstrated consistently, across the board, that these tables have any validity."
Relying on tables derived from single-dose studies is especially problematic with repeated dosing of methadone. The authors noted the FDA's public health advisory on deaths and life-threatening changes in breathing and heart rate in patients newly started on methadone.
Although prescribing a new pain reliever might be necessary because of loss of effectiveness or side effects, in many cases the switch is called for because an insurer no longer covers a particular drug, said Dr. Webster. "So doctors have been forced to move to less costly drugs, and the least costly is usually methadone."
Gambling With Life?
Contributing to the problem is that published equianalgesic tables have inconsistent and variable conversion ratios. In addition, dose conversion guidelines found in package inserts for opioids, particularly the newer extended-release opioids, are inconsistent and potentially dangerous, said Dr. Webster.
He used the example of hydromorphone (Exalgo, Mallinckrodt/Covidien); the language of the insert is such that the conversion would result in 1 of 3 options, he said: an underestimate of the amount of extended-release hydromorphone necessary for adequate analgesia, an overestimate of the necessary amount that could increase the risk for overdose, or a dose within a reasonable window.
This, said Dr. Webster, boils down to "guessing" or "gambling" on the part of the clinician. "When we're dealing with a life, we should not be gambling."
Prescribing competence is "shockingly inadequate," said the authors. Errors can stem from inadequate education, lack of attention to detail, and calculation errors.
Confusion can also contribute to the problem. A survey of 406 non–pain specialist physicians found that 59% had difficulty calculating opioid dosages when rotating. When asked to convert a daily dose of 60 mg oxycodone to the dose for a fentanyl patch, 41% of clinical specialists, 28% of general practitioners, and 17% of geriatric care physicians said they "don't know" how to do that.
Physicians may be lulled into believing that conversion tables are safe and appropriate. "We like to have things structured in medicine," said Dr. Webster. "These tables were established to some degree to provide some security and safety and guidance toward rotating, but the irony is that they've actually made it unsafe."
Research suggests that 50% to 80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.
In their second report, a clinical case also published in Pain Medicine, Dr. Webster and Dr. Fine suggest an alternative to using opioid-rotation tables.
The best approach, they suggest, is to decrease the first drug by 25% to 30% per week while introducing the new drug at a dose that would be given to an opioid-naive patient, increasing the dose according to the clinical response, said Dr. Webster. "In many instances, it may take 3 to 4 weeks to rotate from one opioid to another," he said.
If patients are experiencing pain during the switch, physicians should give an immediate-release opioid to help "bridge" inadequate dosing.
He cautioned that some patients may be sensitive to the new drug. "A new molecule may be highly effective at a very low dose."
Hold Next Dose
Seddon Savage, MD, medical director, Chronic Pain and Addiction Program, Silver Hill Hospital, New Canaan, Connecticut, and president of the American Pain Society, agrees with this slow rotation protocol.
She added that patients should be told that if they feel sedated they should hold their next opioid dose and call their physician.
Dr. Savage commented that the review paper does a good job of pointing out and documenting the problems related to opioid rotation and of making physicians more aware of the limitations of conversion tables.
"One of the points that the authors make is that there is a lot of variability in response to different opioids. If you take these opioid conversion tables as gospel, apply them indiscriminately to all people, and just do a mathematical conversion, you will end up with some people for whom the conversion aren't appropriate."
lunes, 16 de abril de 2012
Martes 17 de Abril.
Hola. Vamos a revisar los receptores mu. (solo mu)
Como se explica en este contexto que 2 personas con similares características demográficas tengan niveles de analgesia y efectos secundarios diferentes luego de una dosis similar de un opioide ?
Cual es la razón por la cual un paciente expuesto a opioides responde de una forma diferente a una dosis estándar de otro opioide ?
Pienso que necesitarán gráficos para explicar sus respuestas.
Como se explica en este contexto que 2 personas con similares características demográficas tengan niveles de analgesia y efectos secundarios diferentes luego de una dosis similar de un opioide ?
Cual es la razón por la cual un paciente expuesto a opioides responde de una forma diferente a una dosis estándar de otro opioide ?
Pienso que necesitarán gráficos para explicar sus respuestas.
martes, 3 de abril de 2012
Martes 10 de abril 2012
Mayra tiene 28 años y fué sometida a una apendicectomía laparoscópica. Tiene como antecedentes de importancia una arritmia cuyo nombre no recuerda por la que tomó un medicamento por varios años (no se acuerda del nombre de este medicamento). Tiene una ulcera duodenal y refiere que es alérgica a los AINEs. Tampoco recuerda a cuales, aunque si se acuerda que se le cerró el pecho en una de esas alergias y tuvo que ser llevada de urgencia a una clinica en Cúcuta.
Su cirujano le decide formular 2 gramos de dipirona cada 8 horas y 30mg de meperidina cada 6 horas.
Que opina del manejo analgésico realizado por su cirujano ?
Por que no usamos dipirona en esta institución ?
Su cirujano le decide formular 2 gramos de dipirona cada 8 horas y 30mg de meperidina cada 6 horas.
Que opina del manejo analgésico realizado por su cirujano ?
Por que no usamos dipirona en esta institución ?
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