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Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

Introduccion : la cirugia micrografica de Mohs se emplea para la escision de tumores cutaneos malignos y frecuentemente es seguida de reconstruccion, prolongando el procedimiento y causando ansiedad y molestia al paciente. Esta cirugia se realiza con anestesia local y sedacion complementaria. Dentro de los anestesicos intravenosos la dexmedetomidina es una excelente opcion; sin embargo, se han reportado casos de bradicardia severa asociado a inestabilidad hemodinamica y riesgo de complicaciones con su uso. Objetivo : describir la frecuencia de bradicardia con repercusion hemodinamica en pacientes llevados a cirugia micrografica de Mohs mas reconstruccion, bajo anestesia loco regional y sedacion con dexmedetomidina. Metodos : estudio observacional descriptivo retrospectivo de 30 pacientes llevados a cirugia de Mohs entre el 1 de noviembre 2012 a 30 de noviembre de 2013. Resultados : el 53,3 % eran mujeres, la edad promedio fue de 68,4 anos, 21,4 % fueron clasificados como ASA I, 53,5 % ASA II y 25 % ASA III. El tiempo quirurgico promedio fue de 184 ± 61 minutos y de anestesia con dexmedetomidina fue 196 ± 65,2 minutos. Solo un paciente requirio atropina durante la cirugia y ningun paciente requirio conversion a anestesia general. Conclusion : la dexmetomidina es una buena alternativa para proporcionar sedacion en los pacientes llevados a cirugia de Mohs bajo anestesia loco-regional, debido a su baja incidencia de bradicardia con repercusion hemodinamica y ausencia de la necesidad de soporte ventilatorio. DOI: http://dx.doi.org/10.21615/cesmedicina.32.2.2

Introduction The use of total intravenous anaesthesia (TIVA) has been growing worldwide over the past 20 years due to the creation of new drugs and the development of new target-controlled infusion pumps, many of which have already been approved in the United States by the FDA (Food and Drugs Administration), in Europe and in Colombia. However, the use of TIVA has not been expanded yet as part of routine practice. Objective To determine the frequency of TIVA use in our country and to identify existing barriers for its implementation. Materials and methods Survey designed to determine the use of TIVA in general anaesthesia practice in Colombia. A representative random sample of the universe of anaesthetists registered in the database of the Colombian Society of Anaesthesiology and Resuscitation (S.C.A.R.E.) was calculated. Reminders were sent by e-mail and some of the selected respondents were contacted by phone. Results Overall, 141 (32.4%) responses were obtained. The frequency of TIVA use was reported as Always, 7 (5.0%), Almost Always, 52 (36.9%), Hardly Ever, 57 (40.4%) and Never, 25 (17.7%). The techology used for TIVA administration included macro drip devices ( n = 30, 21.3%), volumetric pumps ( n = 76, 53.9%), TCI pumps ( n = 45, 31.9%), and computer programmes ( n = 9, 6.4%). The limitations identified for the use of TIVA included low availability of anaesthesia depth monitoring ( n = 68, 48.2%) and infusion pumps ( n = 52, 36.9%), lack of experience ( n = 41, 29.1%), little availability of workshops ( n = 26, 18.4%), low availability of medications ( n = 23, 16.3%), fear of intra-operative recall ( n = 22, 15.6%), limited knowledge of pharmacology ( n = 18, 12.8%), increased anaesthesia time ( n = 13, 9.2%), and perceived difficulty for performing the technique ( n = 13, 9.2%). Conclusions The use of TIVA has been limited by the low availability of technology, lack of experience or knowledge among anaesthetists, and a preference for the balanced anaesthesia technique. Many anaesthesiologists prefer balanced techniques for general anaesthesia. Some devices used for TIVA administration raise concerns about patient safety.

Introduction: The use of total intravenous anaesthesia (TIVA) has been growing worldwide over the past 20 years due to the creation of new drugs and the development of new target-controlled infusion pumps, many of which have already been approved in the United States by the FDA (Food and Drugs Administration), in Europe and in Colombia. However, the use of TIVA has not been expanded yet as part of routine practice. Objective: To determine the frequency of TIVA use in our country and to identify existing barriers for its implementation. Materials and methods: Survey designed to determine the use of TIVA in general anaesthesia practice in Colombia. A representative random sample of the universe of anaesthetists registered in the database of the Colombian Society of Anaesthesiology and Resuscitation (S.C.A.R.E.) was calculated. Reminders were sent by e-mail and some of the selected respondents were contacted by phone. Results: Overall, 141 (32.4%) responses were obtained. The frequency of TIVA use was reported as Always, 7 (5.0%), Almost Always, 52 (36.9%), Hardly Ever, 57 (40.4%) and Never, 25 (17.7%). The techology used for TIVA administration included macro drip devices (n = 30, 21.3%), volumetric pumps (n = 76, 53.9%), TCI pumps (n = 45, 31.9%), and computer programmes (n = 9,6.4%). The limitations identified for the use of TIVA included low availability of anaesthesia depth monitoring (n = 68, 48.2%) and infusion pumps (n = 52, 36.9%), lack of experience (n =41, 29.1%), little availability of workshops (n = 26, 18.4%), low availability of medications (n = 23, 16.3%), fear of intra-operative recall (n = 22, 15.6%), limited knowledge of pharmacology (n = 18, 12.8%), increased anaesthesia time (n = 13, 9.2%), and perceived difficulty for performing the technique (n = 13, 9.2%). Conclusions: The use of TIVA has been limited by the low availability of technology, lack of experience or knowledge among anaesthetists, and a preference for the balanced anaesthesia technique. Many anaesthesiologists prefer balanced techniques for general anaesthesia. Some devices used for TIVA administration raise concerns about patient safety. Introducción: En los últimos 20 años el uso de la anestesia total endovenosa (TIVA) se ha expandido en todo el mundo debido a la creación de nuevos medicamentos y al desarrollo de nuevas bombas de infusión controladas por objetivo, muchas de las cuales ya han sido aprobadas por la Food and Drug Administration en USA, Europa y Colombia; sin embargo, el uso de TIVA aún no se ha expandiendo en la práctica rutinaria de la anestesia. Objetivo: Investigar la frecuencia del uso de TIVA en nuestro país y las limitaciones que actualmente existen. Materiales y métodos: Se diseño una encuesta para determinar el uso de la TIVA en Colombia. Se calculó una muestra aleatoria representativa de los anestesiólogos registrados en la Sociedad Colombiana de Anestesiología. Se enviaron recordatorios por correo electrónico y algunos anestesiólogos seleccionados se contactaron por vía telefónica. Resultados: Se obtuvieron 141 (32,4%) respuestas. La frecuencia del uso de TIVA fue reportada así: Siempre 7 (5,0%), casi siempre 52 (36,9%), casi siempre 57 (40,4%) y nunca 25(17,7%). La tecnología implementada para la administración de TIVA incluyó equipos de macro goteo (n = 30:21,3%), bombas volumétricas (n = 76; 53,9%), bombas de TCI (n = 45; 31,9%) y programas de computador (n = 9; 6,4%). Las principales limitaciones para el uso de TIVA fueron la poca monitorización de la profundidad anestésica (n = 68; 48,2%) y de bombas de infusión (n = 52; 36,9%), falta de experiencia (n = 41; 29,1%), poca disponibilidad de talleres (n = 26; 18,4%), poca disponibilidad de medicamentos (n = 23; 16.3%), temor al recordar intraoperatorio (n = 22; 15,6%), conocimiento limitado sobre farmacología (n = 18; 12.8%), incremento en el tiempo de anestesia (n = 13; 9,2%), y la dificultad percibida de desarrollar la técnica (n = 13; 9,2%). Conclusiones: El uso de TIVA se ha limitado por la poca disponibilidad de tecnología, falta de experiencia, y por que se prefiere la técnica balanceada para la anestesia. Algunos dispositivos usados para la administración de TIVA pueden comprometer la seguridad del paciente.

Introduction Several remifentanil products are commercialized in Colombia though they have never been compared in a clinical setting. Objective The aim of this study was to investigate the pharmacodynamic profile of the branded remifentanil molecule (group O: Glaxo SmithKline Manufacturing S.P.A.) and two unbranded molecules (group A: Laboratorios Chalver de Colombia S.A. and group B: Instituto Biologico Contemporaneo, Argentina) registered in Colombia. Methods We carried out a double-blind, randomized, controlled trial. The branded molecule of remifentanil (group O, n = 29) was compared with the two unbranded molecules (group A, n = 29; group B, n = 32) during anesthetic induction and tracheal intubation in adult patients ASA I without predictors for difficult airway. The target controlled infusion (TCI) doses evaluated were 6, 8 and 10 ng/ml with the Minto model. Induction was complemented with propofol 5 mcg/ml (TCI) with the Schneider model and rocuronium 0.6 mg/kg. The primary outcome was the difference between preintubation (TCI equilirium) and postintubation (maximum measurement within 5 min) mean arterial pressure and heart rate. Results A similar pharmacodynamic profile was observed in all of the studied remifentanil molecules. The differences in the change in heart rate were 1.27 (95% CI −3.11;5.67) with molecule A and 1.40 (95% CI −2.65;5.46) with molecule B compared to molecule O (beats/min). The differences in the change in mean arterial pressure were 1 (95% CI -4.81;6.81) with molecule A and 1.82 (95% CI −4.08;7.74) with molecule B compared to molecule O (mmHg). There was one case of arterial hypotension in each group. Conclusion The results suggest that, from a pharmacodynamic point of view, branded and unbranded remifentanil molecules are similar for laryngoscopy/intubation with TCI doses 6, 8 and 10 ng/ml.

Item does not contain fulltext BACKGROUND: The purpose of medication management in the last days of life is to optimize patient's comfort. Little is known about the medication use in the days before death and how this relates to the care setting. OBJECTIVE: To describe medication use in the last week of life for patients dying in hospital, hospice, and home settings in the Netherlands. DESIGN: Retrospective chart review study. SETTING: A convenience sample of patient records from the three settings in three different regions in the Netherlands that cover more than half the country. MEASUREMENTS: Information about medication use in the last week of life of patients who ultimately died an expected death was registered, including type of medication, start and if applicable stop dates, administration routes, and doses. RESULTS: One hundred seventy-nine records were analyzed. Medications most frequently used in the last week of life were analgesics (n = 168, 94.1%) and psycholeptics (n = 150, 84.7%), in particular by hospice patients. The mean number of medications used per patient was nine during day 7 before death and six on the day of dying. On the day of death, 48 (26.8%) patients used a preventive medication. This percentage was highest for patients dying in the hospital or at home. CONCLUSIONS: Patients who die an expected death receive many medications in the last week of life, part of which are preventive medications. Medication management in patients' final days of life can be improved, especially in the hospital and home setting.

Background: Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH. Objectives: To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes. Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache. Selection criteria: We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH Data collection and analysis: We used the standard methodological procedures expected by Cochrane. Main results: We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture. For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%). In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43). In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH. We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%). Authors' conclusions: There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect. Fil: Arevalo-Rodriguez, Ingrid. Fundación Universitaria de Ciencias de la Salud; Colombia. Universidad Tecnologica Equinoccial; Ecuador Fil: Muñoz, Luis. Hospital de San Jose; Colombia Fil: Godoy-Casasbuenas, Natalia. Hospital de San Jose; Colombia Fil: Ciapponi, Agustín. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Arevalo, Jimmy J.. VU University Medical Center; Países Bajos Fil: Boogaard, Sabine. VU University Medical Center; Países Bajos Fil: Roquéi Figuls, Marta. Iberamerican Cochrane Centre; España

Resumen Introduccion Se ha relacionado la depresion con la ocurrencia de enfermedades cardiovasculares. Parece incrementar el riesgo de muerte en enfermedad coronaria. La presencia de depresion tras un sindrome coronario agudo (SCA) y su relacion con factores socioeconomicos no se ha estudiado en Colombia. Objetivo Describir la frecuencia de depresion y sus factores asociados en pacientes hospitalizados por SCA. Metodos Entre abril y mayo de 2008, se llevo a cabo un estudio de corte transversal en tres unidades de cuidado coronario en Santa Marta, Colombia. La presencia de sintomas depresivos se evaluo con el Inventario de Depresion de Beck (BDI). Se considero depresion si el BDI era ≥ 10. Se probo la relacion entre la presencia de depresion y caracteristicas demograficas, clinicas y paraclinicas. Resultados Se encontro un BDI ≥ 10 (algun grado de depresion) en 21 (63,64%) pacientes; 9 de 10 (91,66%) pacientes sin ingresos fijos presentaron depresion, frente a 12 de 23 (57,14%) con ingresos fijos (p = 0,037). En 8 de 8 (100%) pacientes con inversion patologica de la onda T en el electrocardiograma, se evidencio depresion, frente a 13 de 25 (52%) sin cambios en la onda T (p = 0,014); 17 de 22 (77,27%) pacientes que tenian consumo previo de cigarrillos presentaron depresion, frente a 4 de 11 (36,36%) que nunca habian consumido cigarri llos (p = 0,021). Conclusiones Los sintomas depresivos son altamente prevalentes entre los pacientes que sufren un SCA. El desempleo, la inversion patologica de la onda T y el consumo de cigarrillos parecen estar asociados con la presencia de sintomas depresivos tras un evento coronario agudo.

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ResumenContextoLa administración de sedación con sistemas de infusión controlada a objetivo (TCI) podría ofrecer una alternativa segura para el manejo del malestar de los pacientes llevados a procedimientos endoscópicos gastrointestinales. Sin embargo, no se conoce qué medicamento de los disponibles para TCI es el más apropiado. El objetivo del estudio fue comparar remifentanilo y propofol en TCI para la sedación de pacientes durante procedimientos endoscópicos gastrointestinales.Materiales y métodosSesenta y nueve pacientes que requerían un procedimiento endoscópico gastrointestinal fueron asignados aleatoriamente a recibir una TCI en sitio efecto (TCIe) de remifentanilo (n=30) o propofol (n=39). El desenlace primario fue la satisfacción del paciente. Los desenlaces secundarios incluyeron la satisfacción del gastroenterólogo, se compararon las proporciones de eventos adversos entre los 2 grupos (ocurrencia de arritmias cardiacas, depresión respiratoria leve, depresión respiratoria mayor, bradicardia, hipotensión, dolor, náuseas o vómitos, y ausencia de amnesia) y el nivel de consciencia. Número de registro retrospectivo: NCT01746641.ResultadosLas medianas (rango) de satisfacción del paciente entre remifentanilo y propofol fueron 1 (1-2) y 2 (1-4), respectivamente (Chi2, p

Introduction: Several remifentanil products are commercialized in Colombia though they have never been compared in a clinical setting. Objective: The aim of this study was to investigate the pharmacodynamic profile of the branded remifentanil molecule (group O: Glaxo SmithKline Manufacturing S.P.A.) and two unbranded molecules (group A: Laboratorios Chalver de Colombia S.A. and group B: Instituto Biológico Contemporáneo, Argentina) registered in Colombia. Methods: We carried out a double-blind, randomized, controlled trial. The branded molecule of remifentanil (group O, n = 29) was compared with the two unbranded molecules (group A, n = 29; group B, n = 32) during anesthetic induction and tracheal intubation in adult patients ASA I without predictors for difficult airway. The target controlled infusion (TCI) doses evaluated were 6, 8 and 10ng/ml with the Minto model. Induction was complemented with propofol 5 mcg/ml (TCI) with the Schneider model and rocuronium 0.6 mg/kg. The primary outcome was the difference between preintubation (TCI equilirium) and postintubation (maximum measurement within 5 min) mean arterial pressure and heart rate. Results: A similar pharmacodynamic profile was observed in all of the studied remifentanil molecules. The differences in the change in heart rate were 1.27 (95% CI -3.11;5.67) with molecule A and 1.40 (95% CI -2.65;5.46) with molecule B compared to molecule O (beats/min). The differences in the change in mean arterial pressure were 1 (95% CI -4.81;6.81) with molecule A and 1.82 (95% CI -4.08;7.74) with molecule B compared to molecule O (mmHg). There was one case of arterial hypotension in each group. Conclusion: The results suggest that, from a pharmacodynamic point of view, branded and unbranded remifentanil molecules are similar for laryngoscopy/intubation with TCI doses 6, 8 and 10ng/ml. Introducción: En Colombia se comercializan diferentes moléculas de Remifentanil que nunca han sido comparadas en un entorno clínico. Objetivo: El objetivo de este estudio fue investigar el perfil farmacodinámico de la molécula innovadora de Remifentanil (grupo O: Glaxo SmithKline Manufacturing S.P.A.) y dos moléculas genéricas (grupo A: Laboratorios Chalver de Colombia S.A. y grupo B: Instituto Biológico Contemporáneo, Argentina) registradas en Colombia. Métodos: Se llevó a cabo un experimento clínico doble ciego, aleatorizado, controlado. Se comparó la molécula original de Remifentanil (grupo O, n = 29) frente a las dos moléculas genéricas (grupo A, n = 29; grupo B, n = 32) durante la inducción anestésica e intubación oro-traqueal de pacientes adultos ASA I sin predictores de vía aérea difícil. Se evaluaron las dosis 6, 8 y 10 ng/ml (TCI, Target Controlled Infusion) con el modelo de Minto. La inducción se complementó con Propofol 5 mcg/ml (TCI) con modelo de Schneider y Rocuronio 0.6mg/kg. El desenlace primario se evaluó como las diferencias en la presión arterial media y en la frecuencia cardiaca preintubación (momento en que se alcanza la concentración objetivo en sitio efecto) y posintubación (máximo valor alcanzado en 5 minutos). Resultados: Se observó similitud en el perfil farmacodinámico de las moléculas de Remifentanil estudiadas. Las diferencias en el cambio de frecuencia cardiaca fue de 1.27 (IC 95% -3.11;5.67) con la molécula A y 1.40 (IC 95% -2.65;5.46) con la molécula B frente a la molécula O (latidos/minuto). Las diferencias en el cambio de presión arterial media fue de 1 (CI 95% -4.81;6.81) para la molécula A y 1.82 (IC 95% -4.08;7.74) para la molécula B frente a la molécula O (mmHg). Hubo un caso de hipotensión arterial en cada grupo. Conclusión: Los resultados sugieren que desde un punto de vista farmacodinámico las moléculas innovadora y genéricas de Remifentanil son similares para la laringo-scopia/intubación con dosis TCI de 6, 8 y 10 ng/ml.

Introducción: La tromboelastografía (TEG) es un método para valorar las características de la formación y destrucción del coágulo. Una variedad de aplicaciones han sido sugeridas en la literatura. Objetivo: Proporcionar un resumen acerca del conocimiento actual de las aplicaciones de la TEG. Métodos: Se realizó una búsqueda en la base de datos PubMed hasta julio de 2012 con el término «Thrombelastography [MeSH Terms]». Se analizaron artículos de estudios retrospectivos y prospectivos, revisiones y guías conteniendo información acerca de las aplicaciones de la TEG escritos en inglés y español. Resultados: La búsqueda arrojó 3.139 artículos desde 1962. Se clasificaron en 8 categorías: 862 (27,6%) asociados a enfermedades no quirúrgicas, 294 (9,4%) a trasplante hepático, 711 (22,6%) a investigación básica, 174 (5,5%) a obstetricia, 228 (7,3%) a cirugía cardiovascular, 177 (5,6%) a otras cirugías, 234 (7,4%) a técnicas anestésicas y 459 (14,6%) a fármacos. Conclusión: La TEG como herramienta diagnóstica y para guiar terapia transfusional está en aumento. La TEG aún continúa en estudio en diferentes áreas del conocimiento clínico y aún falta definir adecuadamente los alcances de esta técnica diagnóstica. Es evidente que se debe hacer un uso racional de la TEG, conocer a fondo sus fortalezas y debilidades y continuar explorando nuevas aplicaciones. Introduction: Thrombelastography (TEG) is a method to assess clot formation and destruction. Various applications have been suggested in the literature. Objective: To provide an overview of the current knowledge about TEG applications. Methods: Adatabase search in PubMed was performed up to July 2012 using the term "Thrombelastography [MeSH Terms]". We analysed retrospective and prospective studies, reviews and guidelines with information about the applications of TEG written in English and Spanish. Results: The search resulted in 3139 papers since 1962. These were classified in 8 categories: 862 (27.6%) in non-surgical diseases, 294 (9.4%) in liver transplant, 711 (22.6%) in basic research, 174 (5.5%) in obstetrics, 228 (7.3%) in cardiovascular surgery, 177 (5.6%) in other types of surgery, 234 (7.4%) in anaesthetic techniques, and 459 (14.6%) in relation with medications. Conclusion: The application of TEG as a diagnostic tool and as a guide in transfusion therapy is increasing. Its use is still in development in different clinical fields and the advantages and limitations of this technique still have to be defined. It is evident that thrombelastography should be used with caution, and its strengths and weaknesses as well as new applications must continue to be explored.

El editor lamenta que este articulo es un duplicado accidental del articulo publicado, http://dx.doi.org/10.1016/j.rccar.2014.05.005 . Por este motivo, el articulo duplicado ha sido retirado. La politica de Elsevier sobre articulos retirados esta disponible en: http://www.elsevier.com/locate/withdrawalpolicy .

Introducción: Los inotrópicos, fármacos de uso frecuente en la unidad de cuidado intensivo, se emplean con el fin de mantener la perfusión tisular en los diferentes estados de choque mientras se resuelve la etiología del mismo. Los pacientes programados para cirugía cardiovascular son un subgrupo que con frecuencia requiere tratamiento con estos fármacos en el postoperatorio. Objetivo: Describir la frecuencia y el tipo de fármacos usados para el soporte hemodinámico de pacientes en el postoperatorio de cirugía cardiovascular electiva en la Clínica Fundadores, Bogotá, DC. Métodos: Estudio de corte trasversal, en el que se incluyeron todos los pacientes que ingresaron en la unidad de cuidado intensivo sin requerimiento de soporte hemodinámico farmacológico entre octubre de 2010 y diciembre de 2011 en postoperatorio de cirugía cardiaca. Se extrajeron de las historias clínicas electrónicas la edad, el sexo, el puntaje EuroSCORE, el diagnóstico prequirúrgico, el uso de circulación extracorpórea, el uso de fármacos vasoactivos, los días de estancia en la unidad de cuidado intensivo y la mortalidad.Resultados: Se encontraron 150 registros de cirugía cardiovascular con una edad media de 62,8 anos ˜ (DE 10,5), de los cuales 97 (64,6%) eran hombres. Se encontraron 22 (15%) casos con EuroSCORE en riesgo alto, 93 (62%) en riesgo moderado y 35 (23%) en riesgo bajo. Los diagnósticos prequirúrgicos incluyeron enfermedad coronaria en 105 (70%) pacientes, valvulopatías en 29 (19%), cardiopatía isquémica y valvular en 9 (6%) y comunicación interauricular en 6 (4%). En 57 (38%) casos se empleó circulación extracorpórea con un tiempo medio (RIQ) de 92 (73-114) minutos, de quienes 55 se operaron con clamp aórtico, con un tiempo medio (RIQ) de 75 (52-90) minutos. En 78 (52%) pacientes se utilizó uno o más fármacos vasoactivos, siendo la adrenalina el de mayor frecuencia en 41 (27%) casos. Los pacientes que necesitaron inodilatadores fueron 22 (15%) y recibieron dobutamina. La mediana (RIQ) de estancia en la unidad de cuidados intensivos fue de 3 (2-4) días y murieron 6 (4,7%) pacientes. Conclusión: En casi la mitad de los pacientes en postoperatorio de cirugía cardiovascular se utilizó un agente inotrópico, de los cuales la adrenalina fue la más frecuente, seguida de la norepinefrina; el inodilatador utilizado fue la dobutamina. No se utilizaron inotrópicos sensibilizadores del calcio y en baja frecuencia inhibidores de la fosfodiesterasa III con resultados similares en cuanto a estancia en la unidad de cuidados intensivos y mortalidad respecto a estudios en otras poblaciones. Background: Inotropes are frequently used in the intensive care unit to maintain tissue perfusion in case of shock while the cause is resolved. Patients who undergo cardiovascular surgery will frequently require treatment with these drugs during postoperative care. Aim: To describe the frequency and type of drugs used for the hemodynamic support of patients during the postoperative period of elective cardiovascular surgery at Clínica Fundadores, Bogotá D.C. Methods: Cross-sectional study. All patients in the postoperative period of cardiovascular surgery admitted to the intensive care unit (ICU) without pharmacologic hemodynamic support between October and December 2011 were included. The following variables were obtained from the electronic medical records: age, sex, EuroSCORE, pre-surgical diagnosis, use of cardiopulmonary bypass (CPB), use of vasoactive drugs, days of ICU stay and mortality. Results: One-hundred fifty cases of cardiovascular surgery were found. Patients had a mean age of 62.8 years (SD 10.5), of whom 97 (64.6%) were men. Risk according to Euro SCORE was high in 22 (15%) cases, moderate in 93 (62%) and low in 35 (23%) cases. Pre-surgical diagnoses included coronary artery disease in 105 (70%) patients, valvular disease in 29 (19%) patients, ischemic and valvular cardiomyopathy in 9 patients (6%) and atrial septal defect in 6 (4%) patients. CPB was used in 57 (38%) cases with a median (IQR) time of 92 (73-114) minutes, of whom 55 (52%) patients were operated with aortic clamp, with a median (IQR) time of 75 (52-90) minutes. In 78 (52%) patients one or more vasoactive drugs were used, where adrenaline was used most often (41 patients, 27%). In 22 (15%) patients inodilators were required. These patients received dobutamine. Median (IQR) ICU stay was 3 (2-4) days and 6 (4.7%) patients died. Conclusion: In almost half of patients in the postoperative period of cardiovascular surgery an inotrope was used; the most frequently being adrenaline followed by norepinephrine. The inodilator used in these patients was dobutamine. No calcium sensitizer inotropes were used and in few cases phosphodiesterase III inhibitors were used with comparable ICU stay and mortality to research in other populations.

Depression has been related to the occurrence of cardiovascular diseases, and also appears to increase the risk of death from coronary artery disease. The presence of depression after the occurrence of an acute coronary syndrome (ACS) and its relationship with socioeconomic factors has not been studied in Colombia.To describe the frequency of depression and associated factors in patients hospitalized with an ACS.A cross-sectional study was carried out between April and May 2008 in three coronary care units in Santa Marta, Colombia. The presence of depression was evaluated with the Beck Depression Inventory (BDI). Depression was considered to be present if BDI was equal or greater than 10. The relationship between the presence of depression and demographic, clinic and laboratory characteristics was analyzed.A BDI score ≥10 (any degree of depression) was seen in 21 (63.64%) of the patients. In 9 out of 10 (91.66%) patients without stable income had depression in contrast to 12 out of 23 (57.14%) with stable income (P=.037). Depression was found in in 8 of the 8 (100%) patients with electrocardiographic pathological T wave inversion, in contrast to 13 out of the 25 (52%) without changes in T wave (P=.014). Depression was detected in 17 of 22 (77.27%) patients who smoked cigarettes versus 4 of 11 (36.36%) of patients who have never smoked (P=.021).Depressive symptoms are significantly present in patients suffering an acute coronary syndrome. Unemployment, pathological T wave inversion, and smoking seem to be associated with the presence of depressive symptoms after an acute coronary event.

Context Continuous palliative sedation has been the focus of extensive international debates in the field of end-of-life decision making. Although nurses may be important participants in the performance of continuous palliative sedation, research has focused primarily on the role and experience of physicians. Nurses' experiences differ from that of physicians; they more often describe that continuous palliative sedation is used with the intention of hastening death and to have experienced serious emotional burden. Therefore, it is important to understand the experience of nurses in continuous palliative sedation. Objective To describe nurses' experiences with the decision-making and performance of continuous palliative sedation in terminally ill patients. Methods Cross-sectional study. In 2008, a structured questionnaire was sent to 576 nurses in six professional home care organizations, ten units for palliative care in nursing homes and in-patient hospices and seven hospitals in the western region of the Netherlands. Respondents provided information about the last patient receiving continuous palliative sedation whom they had cared for. Results Two-hundred seventy-seven questionnaires were returned and 199 (71.84%) reported a case of continuous palliative sedation. Nurses felt involved in the decision to use sedation in 84% of cases, albeit to a lesser extent in home care (68.75%, p =0.002). They agreed with the performance of continuous palliative sedation in 95.97% of cases and they proposed the use of continuous palliative sedation in 16.16%. Nurses were present at the start of sedation in 81.40% of cases and reported physicians to be present in 45.22%. In 72.77%, arrangements had been made among caregivers about the coordination of health care regarding the sedation. Conclusion Nurses seem to play an important role in the use of continuous sedation. This role is mainly supportive toward physicians and patients during the decision-making process, but shifts to an active performance of sedation, particularly in settings where they explicitly participate as members of a team. Nurses could develop the practice of palliative sedation by anticipating procedural obstacles in the performance of continuous palliative sedation. We recommend them to become more active participants in the decision-making to improve the care of patients receiving continuous palliative sedation.

Contexto: La administración de sedación con sistemas de infusión controlada a objetivo (TCI) podría ofrecer una alternativa segura para el manejo del malestar de los pacientes llevados a procedimientos endoscópicos gastrointestinales. Sin embargo, no se conoce qué medicamento de los disponibles para TCI es el más apropiado. El objetivo del estudio fue comparar remifentanilo y propofol en TCI para la sedación de pacientes durante procedimientos endoscópicos gastrointestinales. Materiales y métodos: Sesenta y nueve pacientes que requerían un procedimiento endos-cópico gastrointestinal fueron asignados aleatoriamente a recibir una TCI en sitio efecto (TCIe) de remifentanilo (n = 30) o propofol (n = 39). El desenlace primario fue la satisfacción del paciente. Los desenlaces secundarios incluyeron la satisfacción del gastroenterólogo, se compararon las proporciones de eventos adversos entre los 2 grupos (ocurrencia de arritmias cardiacas, depresión respiratoria leve, depresión respiratoria mayor, bradicardia, hipotensión, dolor, náuseas o vómitos, y ausencia de amnesia) y el nivel de consciencia. Número de registro retrospectivo: NCT01746641. Resultados: Las medianas (rango) de satisfacción del paciente entre remifentanilo y propofol fueron 1 (1-2) y 2 (1-4), respectivamente (Chi², p< 0,001). Se encontraron diferencias en la ocurrencia de dolor durante el procedimiento (mediana 2 vs. 1, Chi², p = 0,042), náuseas o vómito (4 vs. 0, Chi², p = 0,01), y ausencia de amnesia (29 vs. 10, Chi², p

Context Observer-based sedation scales have been used to provide a measurable estimate of the comfort of nonalert patients in palliative sedation. However, their usefulness and appropriateness in this setting has not been demonstrated. Objectives To study the reliability and validity of observer-based sedation scales in palliative sedation. Methods A prospective evaluation of 54 patients under intermittent or continuous sedation with four sedation scales was performed by 52 nurses. Included scales were the Minnesota Sedation Assessment Tool (MSAT), Richmond Agitation-Sedation Scale (RASS), Vancouver Interaction and Calmness Scale (VICS), and a sedation score proposed in the Guideline for Palliative Sedation of the Royal Dutch Medical Association (KNMG). Inter-rater reliability was tested with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient. Correlations between the scales using Spearman's rho tested concurrent validity. We also examined construct, discriminative, and evaluative validity. In addition, nurses completed a user-friendliness survey. Results Overall moderate to high inter-rater reliability was found for the VICS interaction subscale (ICC=0.85), RASS (ICC=0.73), and KNMG (ICC=0.71). The largest correlation between scales was found for the RASS and KNMG (rho=0.836). All scales showed discriminative and evaluative validity, except for the MSAT motor subscale and VICS calmness subscale. Finally, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. Conclusion The RASS and KNMG scales stand as the most reliable and valid among the evaluated scales. In addition, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. Further research is needed to evaluate the impact of the scales on better symptom control and patient comfort.