Claudio Nazar J

Delirium postoperatorio: una consecuencia del envejecimiento poblacional

Delirium (acute confusional state) is a common and disabling complication among surgical older people. It is often underdiagnosed and undertreated. Its incidence varies by type of intervention and it is associated with several complications such as functional impairment, cognitive dysfunction, prolonged hospitalization and institutionalization. These increase hospitalization costs and the risk of death. There are precipitating and predisposing risk factors, which increase the susceptibility for postoperative delirium. This condition should be considered as a syndrome of epidemiological importance, which needs to be prevented or treated in a timely manner through a multidisciplinary intervention. The perioperative care of elderly patients involves different medical specialties and is a subject of general knowledge.

EXÁMENES PREOPERATORIOS DE RUTINA EN CIRUGÍA ELECTIVA: ¿CUÁL ES LA EVIDENCIA?

Routine preoperative testing in elective surgery: what is the evidence? Any patient, who is undergoing a surgical or invasive procedure, requiring anesthesia or sedation, needs a preoperative evaluation. This is essential in any type of surgical procedure. Most of the times, clinical evaluation is sufficient to establish perioperative as well as patient’s risk factors. Some of them may be modified during the period close to the intervention, without supplementary testing or consultation to others specialists. Currently, the tendency of specialists is request “routine preoperative testing” sometimes without a previous analysis of the clinical history and physical examination. It has been shown that a healthy young patient, undergoing elective surgery, does not need any test before surgery. Preoperative tests increases health costs and don’t significantly change perioperative patient’s morbidity and mortality. Tests such as chest X-ray, electrocardiogram, hematocrit/hemoglobin, coagulation test, platelet count, blood glucose and pregnancy tests have precise indications and should not routinely be requested to all the surgical population.

CIRUGÍA AMBULATORIA: SELECCIÓN DE PACIENTES Y PROCEDIMIENTOS QUIRÚRGICOS

ambulatory surgery: patients and surgeries selection Outpatient surgery is being performed with increasing frequency due to its significant benefits, including lower costs in health care, and lower incidence of complications and mortality, requiring an appropriate selection of patients and surgeries to be performed in this setting. To select patients and surgeries to be operated on an ambulatory basis, it is relevant an adequate preoperative evaluation. Regarding the risks of patient, it is important the comorbidities and the American Society of Anesthesiologists classification. Risks associated with the type of surgery are divided according to their cardiovascular risk and duration of the procedure. Both will define those suitable for outpatient surgery. Serious complications and associated mortality are infre quents nowadays, therefore it is necessary to take into account other indicators, such as unanticipated hospital admission, hospital readmission and prolonged postoperative stay. There are some patients that require more specific preoperative evaluation, such as the elderly, obese, among others.

Manejo preoperatorio de pacientes con Diabetes Mellitus

La Diabetes Mellitus es una condicion cronica de hiperglicemia que afecta al 9,4% de la poblacion chilena. Estudios han encontrado que los pacientes con Diabetes Mellitus tienen mayor probabilidad de requerir cirugia en comparacion a la poblacion general. La hiperglicemia que presentan los pacientes se ha relacionado al desarrollo de complicaciones infecciosas y cardiovasculares en el periodo postoperatorio. Se ha demostrado que el adecuado control glicemico preoperatorio contribuye a disminuir el riesgo de desarrollar dichas complicaciones. Es por eso que se hace fundamental la evaluacion preoperatoria para poder conocer los valores de glicemia que presenta el paciente y realizar los examenes necesarios para determinar las consecuencias sistemicas que ha desarrollado la Diabetes Mellitus. De esta forma podremos realizar modificaciones en los tratamientos que utilizan los pacientes con el fin de optimizar su condicion previo a la cirugia.

Obesidad y embarazo: implicancias anestésicas

RESUMEN La obesidad es una epidemia a nivel mundial, con mas de 2.000 millones de adultos con sobrepeso u obe-sidad, por lo que cada vez es mas probable enfrentarse a una embarazada obesa en la practica clinica del equipo obstetrico. La obesidad incrementa los cambios fisiologicos del embarazo a nivel cardiovascular, respiratorio, metabolico y gastrointestinal, lo que tiene implicancias clinicas que aumentan los costos en salud y la morbimortalidad materna y fetal. Las embarazadas obesas son un constante desafio para el equipo obstetrico, anestesiologico y de salud, debiendo ser enfrentadas de forma multidisciplinaria para la obtencion de mejores resultados obstetricos y perinatales. El anestesiologo debe tener especial cuidado en el manejo analgesico del trabajo de parto y en la tecnica anestesica para la operacion cesarea. El objetivo central de la siguiente revision es explicar, analizar y desarrollar las principales implicancias anestesicas a las cuales se ve enfrentado el especialista en una embarazada obesa.PALABRAS CLAVE:

Manejo preoperatorio de medicamentos en pacientes hipertensos

Resumen es: La hipertension arterial es una enfermedad con alta prevalencia en la poblacion chilena, llegando a casi el 75% en el grupo de mayores de 65 anos. En el ...

MANEJO PERIOPERATORIO DE PACIENTES CON PATOLOGÍA TIROIDEA Y TRATAMIENTO CRÓNICO CON CORTICOIDES

Resumen Los trastornos tiroideos y el uso cronico de corticoides son frecuentes en la poblacion quirurgica, por lo que es necesario un manejo perioperatorio adecuado en este tipo de pacientes. No existe contraindicacion para una cirugia electiva en pacientes con hipotiroidismo asintomaticos y buen control, no siendo necesario mantener la dosis habitual de levotiroxina el dia de la cirugia, debido a las caracteristicas farmacocineticas del medicamento. Si los pacientes hipotiroideos se encuentran sintomaticos y/o no han alcanzado la fase eutiroidea, deben ser tratados y compensados previo al procedimiento quirurgico electivo. Los pacientes hipertiroideos deben mantener su tratamiento antitiroideo incluso el dia de la cirugia. En el hipertiroidismo sintomatico y/o descompensado existe mayor riesgo de desarrollar una tormenta tiroidea, por lo que no se recomiendacirugia electiva en este tipo de pacientes, la cual debe realizarse una vez logrado un estado eutiroideo. Una estricta monitorizacion en el periodo postoperatorio es clave para prevenir complicaciones. El uso cronico degluco corticoides es frecuente. En estos pacientes existe riesgo de desarrollar insuficiencia suprarrenal aguda ante el estres quirurgico, por lo que antes de una cirugia (electiva o de urgencia) es necesario suplementar concorticoides exogenos, en dosis dependientes del tipo de procedimiento quirurgico a realizarse.

ALERGIA AL LÁTEX EN EL PERÍODO PERIOPERATORIO

latex allergy in the perioperative period Latex or natural rubber latex is a processed plant-based product, extracted from the tropical tree Hevea Brasiliensis. This raw material is widely used in about 40.000 medical and daily-used products. Latex allergy is a relevant pathology in surgical environments that arose after the establishment of universal precautions during the nineties. Risk groups include health-care workers and children with spine bifida who have a preva lence ranging between 2.9-17% and 30-70%, respectively. Latex allergy occurs in a variety of ways in health facilities including hypersensitivity reaction type IV or type I. In the former, chemical substances added to latex trigger the allergic reactions; where allergic dermatitis is the most-frequently found case. In the latter, the reactions are triggered by the contact with latex proteins causing from urticarial to anaphylactic shock and death. Diagnosis of latex allergy is based on a clinical history and/or physical examination associated with a confirmatory test as prick test (latex allergy type I) or cutaneous patches (latex allergy type IV). nowadays, there is no definitive cure for the latex allergy and its treatment is based on allergen avoidance.

PACIENTE ADULTO MAYOR Y CIRUGÍA NO CARDÍACA: ¿QUÉ DEBEMOS SABER?

elderly patient and non cardiac surgery: What should we know? The surgical procedures in elderly patients are and will be more common. They are characterized by greater morbidity and mortality than those in younger patients, so it is essential an appropriate preoperative evaluation, a diligent intraoperative monitoring and a proper management of the postoperative period. The old age has a number of physiological changes and an increased incidence of chronic diseases and together determine a decline in physiological reserve and functional capacity. In the preoperative evaluation is important a systematic assessment of comorbidities and drugs routinely prescribed, “fragility” of these patients due to the surgical procedure and the risk of developing postoperative cognitive deficit. Type of surgery, degree of urgency and patient conditions are the main factors to consider at time to choose type of anesthesia. Common complications include the development of postoperative delirium and postoperative cognitive decline, where efforts should be directed at prevention rather than treatment, because it significantly increases perioperative morbidity.

Manejo preoperatorio de pacientes con enfermedades respiratorias crónicas

Las enfermedades respiratorias cronicas son la tercera causa de muerte en Chile y su prevalencia esta aumentando significativamente en el mundo, por lo cual es muy frecuente que nos encontremos con pacientes con estas patologias sometiendose a procedimientos quirurgicos electivos. En estos casos las complicaciones perioperatorias son mas frecuentes que en la poblacion general, por lo cual es indispensable una adecuada evaluacion y manejo preoperatorio. La presencia de enfermedad pulmonar obstructiva cronica (EPOC) es un predictor mayor de complicaciones postoperatorias y deben indicarse broncodilatadores y corticoides inhalatorios preoperatorios en pacientes con esta patologia que seran sometidos a cirugia electiva, especialmente en la relacionada a cancer pulmonar. Asi mismo, los pacientes con EPOC que se someteran a cirugia de revascularizacion miocardica deben recibir ademas corticoides via sistemica en el periodo preoperatorio. El tabaquismo es otro factor de riesgo independiente para desarrollar complicaciones respiratorias postoperatorias en cirugia toracica, por lo que los pacientes deberian suspender el consumo de tabaco por lo menos 4 semanas antes de la cirugia programada con el fin de disminuir significativamente dichas complicaciones. El asma bronquial mal controlada tambien es un factor de riesgo especifico para desarrollar complicaciones pulmonares postoperatorias, por lo cual estos pacientes deben tratarse preoperatoriamente con broncodilatadores inhalatorios, asociados a corticoides inhalatorios u orales segun la gravedad del asma.