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Postoperative Pain Management
1. Carlos Leal M.D. Director Orthopedic Research Laboratory Director of Knee Surgery & Sports Medicine Fellowship Bosque University Orthopedic Department Bogotá DC, Colombia Current Management of Postoperative Pain
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6. Effective postoperative pain management has a humanitarian role, But there are additional medical and economic benefits for rapid recovery and discharge from hospital.
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9. INJURY GATE Various factors: physical, emotional, cognitive or behavioural open or close the gate PAIN experienced depending on how far gate open or closed
27. IASP Postop Pain Protocols International Association for the Study of Pain
28. Ablation surgery IV Morphine Tens Nerve/Spinal Block Opioid derivates NSAIDS + Codein NSAIDS Aspirin Acetaminophen Pain Intensity Scale Treatment International Association for the study of Pain
42. NSAID Actions Most NSAIDs act as non-selective inhibitors of the ciclooxygenase, inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes Cyclooxygenase catalyzes the formation of prostaglandins and thromboxane from arachidonic acid Prostaglandins act (among other things) as messenger molecules in the process of inflammation.
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47. The widespread use of NSAIDs has meant that the adverse effects of these relatively safe drugs have become increasingly prevalent. Gastrointestinal Renal Cardiovascular Other… NSAIDS Adverse Effects
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50. NSAIDS Cardiovascular Adverse Effects Kearney et al., BMJ 2006;332:1302–1308 A recent meta-analysis of all trials comparing NSAIDs found an 80% increase in the risk of myocardial infarction with both newer COX-2 antagonists and high dose traditional anti-inflammatories compared with placebo All NSAIDs are associated with a doubled risk of symptomatic heart failure in patients without a history of cardiac disease
51. NSAIDS Cardiovascular Adverse Effects In patients with such a history, use of NSAIDs was associated with more than 10-fold increase in heart failure If this link is found to be causal NSAIDs are estimated to be responsible for up to 20% of hospital admissions for congestive heart failure
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53. NSAIDS Renal Adverse Effects In renal failure the kidney is trying to maintain renal perfusion pressure by elevated Angiotensin II levels Angiotensin II also constricts the afferent ateriole into the glomerulus in addition to the efferent arteriole it normally constricts
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55. NSAIDS are good, but more research is needed to improve safety and increase efficacy
56. Discovery of COX-2 Selective inhibition of COX-2 results in anti-inflammatory action without disrupting gastroprotective prostaglandins. Daniel L. Simmons Brigham Young University
57. Discovery of COX-2 COX-1 is a constitutively expressed enzyme with a "house-keeping" role in regulating many normal physiological processes COX-2 is an enzyme expressed in inflammation and it is inhibition of COX-2 that produces the desirable effects of NSAIDs.
58. Discovery of COX-2 OXICAMS and COXIBS Proved Efficacy and Safety FDA and EMEA approval under revision due to validation of Cardiovascular Adverse Effects
89. More Info ? [email_address] chazleal@gmail.com
Editor's Notes
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INFLAMACION y DOLOR: principal causa de consulta m
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Celebrex (Celecoxib): Vida media de 11,2 horas. Dosis de 100 a 200 mg / dia o Bid. Comienzo de la accion en 1 hora. Teratogenico. Metabolismo P 450. Quimicamente es una sulfonamida. Dosis equivalentes Vioxx Vs Celebra: 12.5 mg Vs 200. Dosis equipotentes 25 mg Vs 200 mg/bid.el acetaminofen, que a pesar de tener propiedades analgesicas y antipireticas similares a la de la aspirina no tiene propiedades antiinflamatorias importantes por lo que actualmente no se le considera como un AINE.<number>
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Porque el dolor
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1936: MYOCHRYSINE (sales de oro) para el tratamiento de la Artritis Reumatoide.1949: MSD desarrolla el primer corticoesteroide (CORTONE). 1952: Desarrollo de HYDROCORTONE , un sucesor m
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Modelos de analgesia aguda 120 mg una vez al d
Protocol 039, estudio fase III, Dolor dental POP, Arcoxia 120 mg,Naproxeno 550 mg acetaminofen-code
Protocolo 055, fase III, N=225 pacientes.COCNLUSIONES:Arcoxia 120 superior a placebo en todas la mediciones de analgesia, incluyendo el efecto analg
Estudio 057: Estudio fase III, N= 320 pacientes.CONCLUSIONES:Arcoxia 120 efecto general superior a oxicodona/acetaminof
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Absorci
Metabolismo compartido entre varias sub-familias de CYP. No depende de una sola como otros medicamentos.Uni
Warfarina: Aumenta 13% el tiempo de protrombina. Rifampicina: Disminuyo 65% C de Arcoxia. Metotrexate: ↑28% C (dosis > 120 mg de Arcoxia). IECAS: AINES disminuyen efecto antihipertensivo. Litio: AINES aumentan los niveles plasmáticos de Litio. Anticonceptivos orales: Arcoxia 120 mg aumentó los niveles de etinilestradiol de 37% al 60% posiblemente al inhibirir con una enzima sulfotransferasa comprometida en la sulfatación de los estrogenos (sangrados vaginales, turgencia mamaria), en preparados con más de 35 mcg de EE y 0.5 a 1 mg de norethindrona. Al pensarse en una terapia de remplazo hormonal, debe tenerse en cuenta este incremento de la concentración estrogénica.<number>
Estos efectos secundarios son del programa general (no Medal):Otros efectos secundarios son sabor met
Estos efectos secundarios son del programa general (no Medal):Otros efectos secundarios son sabor met
El programa de seguridad de Arcoxia se dise
Una ventaja fundamental de los Coxibs sobre los AINEs convencionales es el menor potencial de producir eventos adversos GI, incluyendo
En teor
El riesgo cardiovascular de los “coxibs” es dosis dependiente y relativo al tiempo, por tanto se deben de usar a dosis mínimas efectivas y por el menor tiempo posible en pacientes en riesgo cardiovascular…..En pacientes con insuficiencia hep
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Cuatro tipos de modelo de analgesia aguda: Dolor dental, dismenorrea primaria y pop Qx ortop