Martes 15 de Marzo 2016

Federico es un paciente de 36 años previamente sano quien luego de un accidente automotor menor ( un taxi golpea su vehículo en lateral  derecho) presentó de inicio súbito un dolor 10/10 tipo quemonazo en la región anterior de su muslo izquierdo. 

El dolor es persistente y fluctúa de forma intermitente entre 6 y 10 cuando lo califica en una escala verbal análoga. 

Es llevado a urgencias en donde luego de canalizarlo lo manejan con 10 mg de oxicodona y 60 mg de lidocaina. 

Al examen se aprecia un paciente álgico, que no puede deambular por dolor.  Tiene alodinea dinámica en la cara anterior del muslo izquierdo. No parece tener un déficit motor. 

Se le realiza una radiografía de columna, pelvis y fémur los cuales son normales. 

Debido a la persistencia del dolor le realizan una resonancia magnética de muslo la cual es normal y posteriormente una resonancia magnética nuclear de columna que muestra una gran hernia L2L3 foraminal izquierda que presiona la raíz y el ganglio de la raíz dorsal. 

Con este diagnóstico se le inició manejo con betametasona intramuscular una dosis única y pregabalina 75 mg BID y tramadol 50 mg TID. Con este tratamiento a las 48 horas manifiesta una reducción de la intensidad del dolor en un 30%. 

Su ortopedista solicita a radiología que le realicen una inyección de esteroides foraminales en L2L3, el cual es realizado bajo TAC.  Durante el procedimiento que se realiza sin sedación al paciente se le inyecta 20 miligramos de metilprednisolona en 1 mililitro de bupivacaina. El paciente manifiesta súbitamente un dolor severo tipo corriente en ambos miembros inferiores. Posteriormente manifiesta que no siente nada desde la cintura para abajo.  No puede mover sus extremidades inferiores. 

1. Identifique el problema 

2. Que se debería hacer para prevenir este tipo de desenlaces. 

3. Como se maneja. 

5. Como les mencioné deben "dominar" la anatomía de la columna vertebral en especial de los forámenes (de cervical a sacro) 

Estas imágenes les pueden ayudar. 

BJM - Pubmed. 2016. TWO THIRDS OF CLINICAL TRIALS UNPUBLISHED TWO YEARS LATER

By Diana Swift 

Leading academic research centers are doing a poor and variable job of disseminating clinical trial results, according to a cross-sectional analysis published online February 17 in BMJ, and that is leading to serious information gaps and ethical lapses.

Despite there being moral and sometimes legal obligations to circulate results in the public domain, Ruijun Chen, MD, from the Department of Medicine, University of California, San Francisco, and colleagues found that just 29% of completed trials at 51 major research centers had been published 2 years after completion, and a mere 13% had submitted their results to ClinicalTrials.gov.

"There is no excuse for the fact that researchers are using resources and conducting experiments on humans, taking up their time and maybe exposing them to risk, and then failing to report the results. Why, is beyond me," corresponding author Harlan M. Krumholz, MD, a professor of medicine at Yale University, New Haven, Connecticut, told Medscape Medical News.

Delayed data dissemination denies healthcare providers and researchers crucial information. "If all the trial data had been made available in a timely way, then people would have realized the cardiovascular risks of Vioxx [Merck] 2 years before it was taken off the market in 2004," said Dr Krumholz, who coauthored a study of pooled trial data showing increased risk with the drug as early as 2000.

The researchers called for timely action to correct this lapse in commitment to the investigative mission and failure to follow through on the research process. "Additional tools and mechanisms are needed to rectify this lack of timely reporting and publication, as they impair the research enterprise and threaten to undermine evidence based clinical decision making," the authors write.

Identifying centers with at least 40 interventional trials registered on the national database ClinicalTrials.gov and having primary completion dates from October 2007 to September 2010, the investigators looked at the proportion of trials that either published results in peer-reviewed journals or reported them to ClinicalTrials.gov, both overall and within 24 months of completion.

They identified 4347 trials at the 51 centers, 23% of which enrolled more than 100 participants and 33.5% of which investigated cancers and other neoplasms. The studies varied widely in size, phase, design, masking, and randomization.

Overall, the results of 2892 (66.5%) of the trials had been disseminated (defined as published or reported on ClinicalTrials.gov) as of July 2014, with the findings of 1560 trials (35.9%) disseminated within 24 months of completion. In 25.7% of cases, more than 24 months had elapsed from completion to dissemination.

Across institutions, the proportion of trials that disseminated results within 24 months ranged from 16.2% (University of Nebraska) to 55.3% (University of Minnesota), and the proportion published within 24 months of completion extended from 10.8% (University of Nebraska) to 40.3% (Yale University). The overall range for results reported on ClinicalTrials.gov ran from 4.1% (Memorial Sloan-Kettering Cancer Center) to 55.4% (MD Anderson Cancer Center).

The overall rate of dissemination ran from 45.9% at the University of Nebraska to 76.7% at the universities of Minnesota and Rochester. There was also a more than twofold variation from 13.9 (University of California, Irvine) to 28.3 (Boston University) months in median time from study completion to publication or reporting.

Previous studies found similar suboptimal dissemination rates, with 25% to 50% of trials remaining unpublished several years after completion.

Dr Krumholz is at loss to understand the lapse in data sharing, which he considers immoral. "It's not hard to report your results. It only takes about an hour," he said. Nor does reporting to the national trial database jeopardize future publication in a peer-reviewed journal, he said. "Some studies are small, but you have to ask: If the results are not important enough to be reported, was the study important enough to be done? You should not have conducted the study if you can't provide timely results."

He noted that those with concerns about a drug could perhaps tap into trial results circuitously by checking relevant studies registered on ClinicalTrials.gov and asking the investigators directly to share their unreported data.

And although researchers do need adequate time to ensure accurate data, "some, inexplicably, never share their findings," Dr Krumholz said. In his view, less effort should be put into identifying reasons and more into rectifying the unjustifiable status quo: "We can spend our time understanding the causes, or we can just fix it."

Dr Krumholz and two coauthors are recipients of a research agreement from Johnson & Johnson (Janssen), through Yale University, to develop methods of clinical trial data sharing, and of contracts from the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting. Dr Krumholz and one coauthor are recipients of a research agreement from Medtronic, through Yale University, to develop methods of clinical trial data sharing, and of a grant from the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices. Dr Krumholz also chairs a cardiac scientific advisory board for UnitedHealth. The other authors have disclosed no relevant financial relationships. 

BMJ. Published online February 17, 2016

MUCHAS FOTOS DE LA CLINICA DE DOLOR

Pueden verlas haciendo click     Aquí

ASPECTOS FARMACOLOGICOS DE LOS ANALGESICOS EN LOS PACIENTES CON INSUFICIENCIA HEPATICA

v. 1.0. Marzo  2016

Desarrollado por los Doctores Luisa Aguirre, Julio Camelo y Felipe Arenas.
Fellows del programa de especialización en Manejo del Dolor y Cuidados Paliativos

Muchas gracias a los doctores por su colaboración.

Martes de dolor. Marzo 8 2016

Andrea tiene 47 años,  es deportista de alto rendimiento, campeona nacional de tiro  y entrenadora de la liga en modalidad pistola y rifle. Está separada hace 6 años, no tiene hijos y vive sola con su perro.

Pertenece al IDRD (Instituto Distrital de Recreación y Deporte), desde  hace 5 años y recibe beneficios médicos, nutricionales,  fisioterapéuticos y psicológicos gratis mientras tenga un desempeño alto en el deporte. 

Hace menos de 3 semanas comenzó con dolores agudos en su hombro derecho con el que sostiene la pistola. Reporta sentir dolor en sus entrenamientos cuando sube y baja el brazo. Le diagnostican tendinosis de supraespinoso y cambios artrósicos glenohumerales, el campeonato nacional se realizara en un mes en Cali Colombia. . 

Se mantiene diariamente con fisioterapia y entrenamiento exhaustivo. No toma analgésicos por temor a ser calificada como dopada.(doping) 

Al transcurrir el tiempo reporta aumento de su dolor que no puede subir el brazo derecho a más de 30 grados, y su rendimiento ha bajado un 10%. 

Es muy competitiva y muestra una baja tolerancia a las frustraciones.

Faltando 9 días para viajar a Cali le comentan que tiene que operarse y que en lo posible no podrá ir a nacionales por las condiciones físicas en las que está. 

¿Qué problemas se logran identificar?

¿Qué método NO farmacológico se implementaría?

¿Qué tratamiento le puede ofrecer?

Ha muerto el Maestro, Padre y Fundador del WIP, Prithvi Raj

http://youtu.be/xj9FNqeXPbg

Ha muerto Prithvi Raj, y el mundo que lucha contra el dolor llora en su despedida y sabe que será inolvidable y por sus enseñanzas, "inmortal", por su seriedad profesional sus testimonios irrefutables y por su calidez humana para extrañar.  

Prithvi Raj ha sido una de las personas más queridas y respetadas del mundo del dolor, del mundo de las universidades, de las sociedades científicas, investigador, académico, maestro y líder ejemplar, que desarrolló muchas técnicas que quedarán como parte de su enorme legado, autor de muchos libros, cientos de papers, que impulso la Sociedad Americana de Anestesia Regional, el proceso más respetado de Certificación y el World Institute of Pain, que junto a David Neeve lucho por el derecho de las personas a vivir sin dolor y junto a su socio del alma Gabor Racz llevaron la medicina del dolor intervencionista al más alto escalón de reconocimiento como ciencia.

Llora el mundo del dolor, y muchos médicos se sentirán extraviados por algún tiempo, sufrirán no poder ir a abrazarlo o a preguntarle algo cuando visiten los talleres de Racz y Heavner en Budapest, pero en algún momento las lágrimas se secarán y recordaran sus enseñanzas y su calidez e inflaran el pecho al decirle a sus pacientes y colegas o a discípulos que conocieron a Prithvi Raj, extraordinaria persona y maestro inspirador, que aprendieron de él y que algunos tienen una foto con él.

Desde las 6 de la mañana que Kris Vissers (Presidente del WIP) envío la triste comunicación se sucedieron innumerables testimonios que indican el impacto mundial de semejante pérdida.

El Mundo del dolor esta de Luto y da sus condolencias a la bella familia de Prithvi Raj y a todos aquellos que aman la medicina gracias a la impronta de estos maestros que gracias a Dios todavía existen....

Juan Carlos Flores

Prof Doctor en Medicina FIPP

Director CAIDBA EPP Award

Chairman Latin American Section World Institute of Pain

BIOGRAFÍA 

World Institute of Pain :: P. Prithvi Raj, M.D. 

P. Prithvi Raj, M.D.

1950 B.Sc. Presidency College, Madras, India. 1958 M.B.B.S. Government Medical College Mysore, India Dr. Raj has done extensive postgraduate work. He has held many positions in the medical field from house surgeon to Orthopedic Registrar in India and England. Dr. Raj did Rotating Internship in Connecticut and his Residency in Anesthesiology in Texas. He has also held positions in Anesthesiology in Norway, England, Texas, California, Ohio and Georgia. His last position before retiring was Professor of Anesthesiology and Co-Director of the International Pain Institute at Texas Tech University Health Sciences Center. He is past president of the World Institute of Pain and an active member of many other professional organizations and committees. In his professional career he has received the following certificates, fellowships and diplomas. 2005     American Board of Interventional Pain Physicians 2000     Fellow of Interventional Pain Practice (FIPP)Added Qualification in Pain Management - (ABA) 2003     Rectification 1992     Diplomate American Board of Pain Medicine (DABP) 1971     Diplomate American Board of Anesthesiology (DABA) 1968     Fellow in the Faculty of Anesthetists of The Royal College of Surgeons of England F.F.A.R.C.S.  1966     Fellow - American College of Anesthesiologists (FACA) Dr. Raj has earned numerous awards and honors and is listed in the “Best Doctors in America” in Chronic Pain Management. He has contributed to over 138 articles, edited numerous editorials, and is presently Editor-in-Chief (Emeritus) of Pain Practice. To add to his credits are twelve books, movies, videotapes, models and exhibits. During his professional career he has received the following significant honors and awards. 1980     Ray Robertazzi Memorial Lecture             "Organization and Purpose of Multi-disciplinary Pain Clinic"             New York State Medical Society             Annual Scientific Session 1990     The Gaston Labat Award, ASRA 1995     Nils Lofgren Award             Astra Pharmaceuticals             For Outstanding Contributions to the Field of Regional Anesthesia  1995     Distinguished Academician             Academy of Medicine             Singapore 1996     Clinician of the Congress             7th International Congress             The Pain Clinic             Istanbul, Turkey  2000     Carl Koller Award - ESRA 2001     Outstanding achievements in Regional Anesthesia & Pain Medicine worldwide.             TTUHSC             Department of Anesthesiology & Pain Management             Budapest, Hungary 2001     Honorary Member              Catalan Pain Society              Barcelona, Spain  2002     Career Excellence in Pain Medicine              American Neuromodulation Society              Orlando, Florida  2002     Honorary Member              The Israel pain Association              Tel-Aviv, Israel  2003     Premio Guido Moricca Award              Sardinia, Italy  2003     Lifetime Achievement Award             Foundations of Interventional Pain Management             San Diego, California 2004     Honorary Member              Turkish Society of Algology             Istanbul, Turkey 2005     Distinguished Service Award             ASRA             Toronto, Canada 2007     Traweek Lecture             TTUHSC             Lubbock, Texas 2007     Recipient of Founding Father's Medal             ASRA             Vancouver, Canada

 

    

Martes Primero de Marzo 2016

Hola. Vamos a revisar las Guías Prácticas para la Prevención, Detección y Manejo de la Depresión Resporatoria asociada a la administración neuroaxial de opioides 

https://app.box.com/s/854lw326j62jnj860tx5671xn9m8ewde

La reunión no sólo busca revisar las recomendaciones  de las guías sino los mecanismos de acción de los opiodes al ser administrados por vía espinal. 

Martes 23 de Febrero 2016.

A András tiene 48 años.  Es obeso con un IMC de 32, hipertenso controlado con losarán y dislipidémico.

Hace 8 dias estuvo en un asado en donde comió y bebió en exceso. Posteriormente presenta dolor abdominal difuso y dolor dorsal. Tuvo nauseas y emesis con episodios frecuentes. Es llevado al centro de salud de Cota en donde manejan con líquidos endovenosos y buscapina compuesta.  Un cuadro hemático muestra 23000 leucocitos.

Por persistencia del cuadro doloroso es remitido a la Fundación SantaFe .  El dolor es severo 9/10. Le administran en total 15 miligramos de morfina y un gramo de acetaminofén.  Las amilasas están en 2000. Es llevado a UCI.

1. Cual es el problema ?
2.  Cuales vias del dolor están implicadas en las manifestaciones clínicas que tiene este paciente ?
3. Por que tiene nauseas y vómito ?  Cuales son las vías nerviosas que median este síntoma?
4. Manejo analgésico

Martes 16 de Febrero 2016

Daniela es una paciente de 46 años. Previamente sana. Hace una semana tuvo una herida en muslo con un elemento cortante presentando una lesión de la arteria femoral profunda a nivel del tercio medio del muslo. Presenta un sangrado agudo que es manejado inicialmente con un torniquete. Ingresa al hospital con tensión arterial de 80/40 y frecuencia cardiaca de 120 por minuto.  Siempre estuvo consciente. En el hospital es llevada a salas de cirugía en donde bajo anestesia general con Remifentanil y sevofluorane le realizan una rafia sin complicaciones. Recibe 100 mg de Ketoprofeno y 1 mg de hidromorfona con lo que presenta adecuado control del dolor.  Se descartó lesión nerviosa. Se transfunde con 2 unidades de glóbulos rojos empaquetados. 

La paciente continúa siendo manejada con Ketoprofeno 60 mg BID ( 2 dosis) , acetaminofen y rescates de hidromorfona los cuales no usa. El dolor es calificado como 2/10 en la región d ela herida quirúrgica. 

Fue dada de alta 48 horas después de su ingreso. 

Hoy ingresa a urgencias ya que ha tenido dolor de cabeza y está con edema en la cara y en los miembros inferiores . 

Tiene una presión arterial de 160/100 frecuencia cardiaca de 64.  Sus leucocitos están en 10000, la hemoglobina en 11,5.  La Cratinina está en 1,8. 

1 Cuales son los problemas

2. Identifique las posibles causas 

3. Cuál es el manejo. 

MEDPULSE. FDA unveils sweeping changes to opioids policies

Journalist

Megan Brooks

Freelance writer, Medscape

Disclosure: Megan Brooks has disclosed no relevant financial relationships.

In response to the ongoing opioid abuse epidemic, top officials at the US Food and Drug Administration (FDA) today announced plans to reassess the agency's approach to opioid medications.

"We are determined to help defeat this epidemic through a science-based and continuously evolving approach," Robert Califf, MD, the FDA's Deputy Commissioner for Medical Products and Tobacco, said in a news release. "This plan contains real measures this agency can take to make a difference in the lives of so many people who are struggling under the weight of this terrible crisis."

The plan is further outlined in an article published online today in the New England Journal of Medicine.

"Nationally, the annual number of deaths from opioid overdoses now exceeds the number of deaths caused by motor vehicle accidents," write Dr Califf and coauthors Janet Woodcock, MD, and Stephen Ostroff, MD, also from the FDA. "Regardless of whether we view these issues from the perspective of patients, physicians, or regulators, the status quo is clearly not acceptable. As the public health agency responsible for over-sight of pharmaceutical safety and effectiveness, we recognize that this crisis demands solutions. We are committed to action, and we urge others to join us."

The multicomponent plan will focus on policies aimed at reversing the epidemic, while still providing pain patients access to effective medication. Specifically, the FDA plans to:

* Re-examine the risk-benefit paradigm for opioids and ensure that the agency considers their wider public-health effects;

* Convene an expert advisory committee before approving any new drug application for an opioid that does not have abuse-deterrent properties;

* Assemble and consult with the Pediatric Advisory Committee regarding a framework for pediatric opioid labeling before any new labeling is approved;

* Develop changes to immediate-release opioid labeling, including additional warnings and safety information that incorporate elements similar to those of the extended-release/long-acting (ER/LA) opioid analgesics labeling that is currently required;

* Update Risk Evaluation and Mitigation Strategy requirements for opioids after considering advisory committee recommendations and review of existing requirements;

* Expand access to, and encourage the development of, abuse-deterrent formulations of opioid products;

* Improve access to naloxone and medication-assisted treatment options for patients with opioid-use disorders; and

* Support better pain-management options, including alternative treatments.

The FDA says they will seek guidance from outside experts in the fields of pain management and drug abuse. The agency has already asked the National Academy of Medicine to assist in developing a framework for opioid review, approval, and monitoring that balances an individual's need for pain control with considerations of the broader public-health consequences of opioid misuse and abuse.

The FDA says it will convene independent advisory committees made up of physicians and other experts when considering approval of any new opioid drug that does not contain abuse-deterrent properties. The agency will also convene a meeting of its standing Pediatric Advisory Committee to provide advice on a framework for pediatric opioid labeling and use of opioid pain medications in children.

The FDA also plans to tighten requirements for drug companies to generate postmarket data on the long-term impact of using ER/LA opioids, an action, they say, that will generate the "most comprehensive data ever collected in the field of pain medicine and treatments for opioid use disorder. The data will further the understanding of the known serious risks of opioid misuse, abuse, overdose and death."

Drug overdose deaths, driven largely by overdose from prescription opioids and illicit drugs like heroin and illegally-made fentanyl, are now the leading cause of injury death in the United States.

"Things are getting worse, not better, with the epidemic of opioid misuse, abuse and dependence," Dr Califf said in the FDA statement. "It's time we all took a step back to look at what is working and what we need to change to impact this crisis."

"Agencies from across the Department of Health and Human Services and throughout the federal government are united in aggressively addressing this public health crisis," US Health and Human Services (HHS) Secretary Sylvia M. Burwell, said in the news release. "The FDA is a vital component to combating this epidemic, and the innovation and modernization they have committed to undertaking is an important part of the overall efforts at HHS."

Last spring, HHS announced a major initiative to address the opioid abuse epidemic in the US. The initiative focuses on informing opioid prescribing practices, increasing the use of naloxone, and using medication-assisted treatment to move people out of opioid addiction.

The FDA says it will provide updates on progress with the goal of sharing timely, transparent information on a regular basis.

NEJM. Published online February 4, 2016. Abstract