Colico renal mbe 2009 Paulo Portalier
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Transcript of Colico renal mbe 2009 Paulo Portalier
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Medicina Basada en la evidencia
Una aproximación desde la clínica
DefiniciónUso explícito y juicioso de la mejor evidencia disponible en la toma
de decisiones
“mejor evidencia disponible“
“explícito y juicioso”
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Guías de PrácticaClínica
Las guías de prácticaclínica son un
términointroducido en 1990 por el Instituto de
Medicinanorteamericano
¿Porqué son necesariaslas GPC?
Las GPC intentandarrespuesta a la variabilidad
en la prácticamédica no explicable
porlascircunstanciasclínicasconcretas de los
pacientes
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Problemas concretos de la
asistencia sanitaria actual
La toma de decisiones en la práctica clínica viene condicionada por una serie de
problemas concretos de la asistencia sanitaria actual, derivados entre otros de:
a) Incertidumbre de la práctica clínica
b) Dificultades en la asimilación de conocimientos: la llamada “paradoja de la
información” donde, a pesar de la abundante literatura médica disponible (libros de texto,
revistas, artículos de investigación, etc.), el clínico es incapaz de controlar la avalancha de
información existente, a veces, con resultados contradictorios.
c) Falsas presunciones/ignorancia:
d) Disponibilidad de los recursos
e) Necesidad de criterios de uso apropiado / estándares de calidad
f) Presiones externas:
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¿Cuando son necesarias las GPC? a) Problemas de salud con impacto clínico (prevalencia, morbimortalidad).
b) Amplia variabilidad de la práctica clínica.
c) Ausencia de consenso en el manejo de una patología determinada.
d) Aparición de nuevas evidencias (tratamiento, diagnóstico, prevención).
e) Pruebas diagnósticas o tratamientos con efectos indeseables o costesinnecesarios.
f) Líneas estratégicas de las organizaciones sanitarias.
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Tipos de GPC
En función del métodoutilizadopara la
elaboración de las GPC, éstas se
puedenclasificar en
Basadas en la opinión de expertos.
Basadas en el consenso,
másomenos formal.
Basadas en la evidencia.
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Level of evidence (LE)
Guia Urolitiasis. EAU.
Update Marzo 2008
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi- experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies
and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
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Grade of recommendation(GR)
Guia Urolitiasis. EAU.
Update Marzo 2008
Grade Nature of recommendations
A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at
least one randomized trial
B Based on well-conducted clinical studies, but without randomized clinical trials
C Made despite the absence of directly applicable clinical studies of good quality
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La gestión por procesos instrumentoimportante para la gestión de los
centros sanitarios.
unavisión horizontal de la organización,
el paciente se convierte en eje esencial entorno
al cual se planifican las actuaciones, se toman
las decisiones, y seorganizan las actividades.
la herramienta que se diseñó fue la “Guía
Integrada Asistencia”,
las actividades asistenciales
no asistenciales.
El problema a resolver en el control de
procesos,
es conseguir que la variabilidad de cada
categoría esté dentro de un límite,
de forma que la variabilidad delos resultados,
esté situada también dentro de unos limites
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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Journal of Urology
2007
Meta-analysis of alpha blockers versus
control showed
an absolute increase of 29% in the stone-
passage rate (95% CI: 20% to 37%),
which was statistically significant.
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Spasmolytics indication in renal colic: a literature review
Spasmolytics are often prescribed by general practitioners or by emergency services as soon as renal colic is diagnosed. This practice has however been widely contested. This article presents a literature review on the efficiency of spasmolytics for the treatment of renal colic. Furthermore, it draws a comparison with daily practice, and finally summarizes side effects of this treatment.
CONCLUSION: Based on the EBM review, it cannot be concluded that spasmolytics are effective in renal colic. A better practice is to use diclofenac as a unique drug, and to complement the treatment with tramadol and antalgics for uncontrolled patients. Furthermore, the use of tamsulosin is proved to be efficient for lithiasis in the lower part of the ureter.
•Rev Med Liege. 2009 Jan;64(1):45-8. Links
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Tto del dolor
Agregar alfa bloqueadores (o nifedipino)
Si dolor persiste pigtail, extracción o nefrostomía
Uso AINES no afecta fx renal en riñones
normales. Podría en fx renal disminuida.
(LE = 1b; GR = A)
Guia Urolitiasis. EAU.
Update Marzo 2008
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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Procedimientos
diagnósticos
Gold Standard: PGE (S 75% E 93%)
Actualmente mejor: PieloTAC. (S 97% E 95%)
Especificidad y Sensibilidad ≥ PEG
Detecta litos radiolúcidos: ác. úrico o cistina
Aporta diagnóstico diferencial
Alternativa: Rx RVS y ECO R y Pelviana
(S 55% E 75%) (S 19% E 97%)
Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
Table 5: Imaging modalities in the
diagnostic work-up of patients with acute
flank pain
1 Non-contrast CT (LE 1 GR A)
1 Excretory urography (Standard procedure)
2 KUB + US (LE 2a GR B)
LE = level of evidence; GR = grade of recommendation; CT = computed tomography; KUB =
plain film of kidney, ureters and bladder; US = ultrasonography
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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Guia Urolitiasis. EAU.
Update Marzo 2008
“Insertion of an internal stent before ESWL
is recommended for stones with a diameter
> 20 mm (~300 mm2)”
LE = 3 GR = B
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“Tubeless percutaneous nephrolithotomy, with or
without tract fulguration, application of a sealant
or double-J stenting, is a safe alternative in
uncomplicated
cases “
(LE = 1b; GR = A).
Guia Urolitiasis. EAU.
Update Marzo 2008
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Ureterorrenoscopía
Uso de Canastillos o Fórceps:
Rápido y con < morbilidad que litotripsia
Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
Litiasis renal > 1 cm
Con Pigtail Sin Pigtail
= Stone Free
Uso rutinario de stent no mejora el
logro de este objetivo
LE 1b, GR A
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Indicaciones para
extracción activa
Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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Guia Urolitiasis. EAU.
Update Marzo 2008
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ETAPAS DEL MANEJO
DEL CÓLICO RENAL
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HIPOTESIS DIAGNÓSTICA
• Síntomas
• Signos
DIAGNÓSTICO SINDROMÁTICO
DIAGNÓSTICO
ETIOLÓGICO
Nefrolitiasis
Ureterolitiasis
PREVENCIÓN
DIAGNÓSTICO
DIFERENCIAL
CONDICIONESPACIENTE
RTA. A TRATAMIENTO
EVOLUCIÓN
COMPLICADO
TRATAMIENTOESTUDIO
TRATAMIENTO ESTUDIO ESTUDIO
TRATAMIENTO
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PROTOCOLOS O PAUTAS DE
RECOMENDACIÓN CLÍNICA
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"Si buscas resultados diferentes,
no sigas haciendo lo mismo“
Albert Einstein
"¡Sonamos muchachos!
¡Resulta que si uno no se apura a cambiar el mundo,
después es el mundo el que lo cambia a uno!"
Mafalda
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HIPOTESIS DIAGNÓSTICA
• Síntomas
• Signos
DIAGNÓSTICO SINDROMÁTICO
DIAGNÓSTICO
ETIOLÓGICO
Nefrolitiasis
Ureterolitiasis
PREVENCIÓN
DIAGNÓSTICO DIFERENCIAL
CONDICIONESPACIENTE
RTA. A TRATAMIENTO
EVOLUCIÓN
COMPLICADO
TRATAMIENTOESTUDIO
TRATAMIENTO ESTUDIO ESTUDIO
TRATAMIENTO