Anestesia local en pacientes reumáticos. Avances y perspectivas

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Abstract

RESUMEN Introducción: las enfermedades reumáticas y muscoloesqueléticas se manifiestan por alteraciones en el aparato locomotor, aunque detrás de ellas puede haber un trastorno de la respuesta inmunológica que conlleva a que la atención de estos pacientes no se deba centrar solo en los aspectos locales, sino también en su valoración sistémica por la afectación de órganos y sistemas de órganos como el cardiovascular, respiratorio, renal y digestivo. Objetivo: revisar los avances y tendencias actuales del uso de la anestesia local en pacientes con enfermedades reumáticas. Desarrollo: el tratamiento de estas enfermedades está constituido fundamentalmente por glucocorticoides los antinflamatorios no esteroideos y los fármacos modificadores de enfermedad, además de que cada vez más están disponibles medicamentos antirreumáticos, aunque algunos aún requieren de mayor evidencia para su utilización generalizada. Conclusiones: la anestesia local es una de las alternativas terapéuticas que generalmente, por vía intra articular, se emplea en los pacientes reumáticos, al igual que otros medicamentos. En la búsqueda de nuevas sustancias que induzcan mayores períodos de analgesia se ha incursionado en el empleo de adyuvantes o aditivos, que son medicamentos que se asocian de manera de sinérgica con los anestésicos locales y prolongan la duración del bloqueo sensorio-motor, atenuando la sensación dolorosa y esto permite restringir la dosis acumulativa requerida de anestésicos locales. Se reportan importantes avances en este sentido y se amplían las perspectivas por los resultados de las investigaciones.

Translated abstract

ABSTRACT Introduction: rheumatic diseases and musculoskeletal diseases are manifested by alterations in the locomotors system, although behind them there may be a disorder of the immune response that leads to the attention of these patients should not focus only on the local aspects, but also in its systemic assessment for the involvement of organs and organ systems such as cardiovascular, respiratory, renal and digestive. Objective: To review current advances and trends in the use of local anesthesia in patients with rheumatic diseases. Development: The treatment of these diseases consists mainly of glucocorticoids, non-steroidal antiinflammatory drugs and disease modifying drugs, in addition to which antirheumatic drugs are increasingly available, although some still require more evidence for its widespread use. Conclusions: Local anesthesia is one of the therapeutic alternatives that is generally used intraarticularly in rheumatic patients, as well as other medications. In the search for new substances that induce longer periods of analgesia has been intruded into the use of adjuvants or additives, which are drugs that are associated in a synergistic manner with local anesthetics and prolong the duration of sensorimotor block, attenuating the sensation painful and this allows to restrict the required cumulative dose of local anesthetics. Important advances are reported in this regard and perspectives are broadened by the results of the investigations.

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Adjuvants to local anesthetics: Current understanding and future trends

Amlan Swain, Deb Nag, Seelora Sahu … (2017)

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

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Comorbilidades y calidad de vida en Osteoartritis

Urbano Solis Cartas, Silvia Johana Calvopiña Bejarano (2018)

RESUMEN Introducción: la osteoartritis es considerada la enfermedad reumática más antigua y frecuente que existe. A pesar de ser considerada una patología benigna se asocia a un gran número de comorbilidades que pueden influir en el curso de la enfermedad. Objetivo: determinar la influencia de las comorbilidades en la percepción de la calidad de vida relacionada con la salud en pacientes con osteoartritis del cantón Riobamba. Método: estudio descriptivo, transversal y observacional en 1263 pacientes con diagnóstico de osteoartritis. Se utilizó el cuestionario de láminas Coop/Wonca para determinar percepción de calidad de vida relacionada con la salud. Se determinó el valor del coeficiente alfa de Cronbach para evaluar la consistencia interna y fiabilidad del cuestionario. Resultados: promedio de edad de 71,83 años, predominio del sexo femenino y grupo de edades entre 66 y 75 años. Las articulaciones más afectadas fueron las rodillas, seguidos de las manos, columna vertebral y caderas respectivamente. Existió un alto por ciento de comorbilidades asociadas (72.13 %), con destaque para la hipertensión arterial, la diabetes mellitus, el síndrome metabólico y el hipotiroidismo, las que se presentaron por encima del 10 % del total de pacientes. Valores globales de calidad de vida superiores a los 20 puntos. Las dimensiones más afectadas fueron el dolor, la forma física y las actividades cotidianas. Conclusiones: la presencia de comorbilidades empeoró la percepción de CVRS de los pacientes con OA, por lo que se debe tener una vigilancia estricta sobre la aparición o descompensación de las mismas.

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Joint aspiration and injection and synovial fluid analysis.

Philip Courtney, Michael F Doherty (2013)

Joint aspiration/injection and synovial fluid (SF) analysis are both invaluable procedures for the diagnosis and treatment of joint disease. This chapter addresses (1) the indications, technical principles, expected benefits and risks of aspiration and injection of intra-articular corticosteroid and (2) practical aspects relating to SF analysis, especially in relation to crystal identification. Intra-articular injection of long-acting insoluble corticosteroids is a well-established procedure that produces rapid pain relief and resolution of inflammation in most injected joints. The knee is the most common site to require aspiration although any non-axial joint is accessible for obtaining SF. The technique involves only knowledge of basic anatomy and should not be unduly painful for the patient. Provided sterile equipment and a sensible, aseptic approach are used, it is very safe. Analysis of aspirated SF is helpful in the differential diagnosis of arthritis and is the definitive method for diagnosis of septic arthritis and crystal arthritis. The gross appearance of SF can provide useful diagnostic information in terms of the degree of joint inflammation and presence of haemarthrosis. Microbiological studies of SF are the key to the confirmation of infectious conditions. Increasing joint inflammation associates with increased SF volume, reduced viscosity, increasing turbidity and cell count and increasing ratio of polymorphonuclear:mononuclear cells, but such changes are non-specific and must be interpreted in the clinical setting. However, detection of SF monosodium urate and calcium pyrophosphate dihydrate crystals, even from un-inflamed joints during intercritical periods, allows a precise diagnosis of gout and calcium pyrophosphate crystal-related arthritis.