ABSTRACT
La Neumonía Asociada a la Ventilación Mecánica (NAVM) afecta entre 10 por ciento y 65 por ciento de los pacientes, con una mortalidad atribuible que fluctúa entre 24 por ciento y 76 por ciento. Numerosas directrices recomiendan dividir la NAVM en precoz si ocurre dentro de las primeras 96 horas de ingreso a UCI o tardía si es posterior, ya que las tardías suelen ser ocasionadas por patógenos multirresistentes (PMR). Objetivo: Determinar si hay asociación entre la presencia de PMR con la NAVM tardía, uso previo de antibióticos, comorbilidady gravedad al ingreso a la UCI. Métodos: Estudio prospectivo de 12 meses. El diagnóstico de NAVM fue clínico asociado a cultivo cuantitativo en contaje significativo (106 UFC/ml para cultivo cuantitativo de aspirado endotraqueal, 104 UFC/ml para lavado broncoalveolar (LBA) vía broncoscópica). Resultados: Se enrolaron 48 pacientes con NAVM consecutivos, 19 mujeres, la edad promedio fue de 59+/-18,5 años. Los principales gérmenes involucrados fueron St Aureus meticilino resistente (54 por ciento), Acinetobacter sp (33 por ciento) y Pseudomonas aeruginosa (19 por ciento). El aislamiento de PMR no se asoció significativamente a la NAVM tardía (p >0,05), por el contrario el uso previo de antibióticos se relacionó más estrechamente con la presencia de PMR (p <0,0001). Al analizar variables clínicas sólo la escala de Glasgow más baja al ingreso a la UCI se asoció significativamente con la presencia de PMR (10,7+/-3,3 vs14,5+/-0,5, p <0,05). Conclusión: El uso previo de antibióticos se asocia significativamente a la neumonía por PMR independiente del momento en que se diagnostica la NAVM.
Ventilator-associated pneumonia (VAP) is a mechanical ventilation complication that affects about 10 percent to 65 percent of mechanical ventilated patients. The attributable mortality ranged between 24 percent to 76 percent. Most of the guidelines have recommended to classify VAP in early onset if diagnosis is made in the first 96 hours from ICU admission or late onset if the diagnosis is later. Early onset VAP is reported to be due to antibiotic-sensitive pathogens, while late-onset VAP is frequently attributed to antibiotic-resistant pathogens (ARP). The Aim of the study was to correlate the isolate of ARP with late-onset VAP, prior antimicrobial treatment, comorbidity and severity of illnesses. Methods: 12 months prospective study. VAP was define according a presumptive clinical diagnosis plus an isolation of a pathogen in a significant concentration (>106 CFU/ml for quantitative cultures of endotracheal aspirates, >104 CFU/ml for bronchoalveolar lavage from fiberoptic bronchoscopic). Results:We included 48 patients with VAP, 19 women, the average age was 59 +/- 18,5 years. 75 percent (36/48) were late-onset VAP. The organism most frequently isolated was methicillin resistant S. aureus (54 percent), Acinetobacter sp (33 percent), and Pseudomona aeruginosa (19 percent). ARP was not associated with late-onset VAP (p >0,05), by contrast prior antimicrobial treatment was closely associated to isolation of ARP (p<0,001). When analyzed clinical variables only lower Glasgow coma scale at ICU admission was associated with ARP-VAP (10,7+/-3,3 vs 14,5+/-0,5 p <0,05). Conclusion: Prior antimicrobial treatment was closely associated with ARP-VAP regardless of the timing of VAP Diagnosis.
Subject(s)
Humans , Male , Adolescent , Adult , Female , Middle Aged , Aged, 80 and over , Drug Resistance, Microbial/physiology , Pneumonia/etiology , Pneumonia/microbiology , Respiration, Artificial/adverse effects , Anti-Bacterial Agents/therapeutic use , Bacterial Physiological Phenomena , Bacteria/isolation & purification , Bacteria , Culture Techniques , Intensive Care Units , Cross Infection/microbiology , Pneumonia, Bacterial/etiology , Pneumonia, Ventilator-Associated , Prospective Studies , Risk Factors , Time FactorsABSTRACT
Background: Hypertriglyceridemia over 1,000 mg/dl can provoke acute pancreatitis and its persistence can worsen the clinical outcome. On the contrary, a rapid decrease in triglyceride level is beneficial. Plasmapheresis has been performed in some patients to remove chylomicrons from the circulation, while heparin and/or insulin have been administered in some other cases to rapidly reduce blood triglycerides. Heparin and insulin stimulate lipoprotein-lipase activity and accelerate chylomicron degradation. Aim: To report five patients with acute pancreatitis treated with heparin and insulin. Patients and methods: Five patients (4 females and 1 male) seen in the last two years, who suffered acute pancreatitis induced by hypertriglyceridemia are reported. Initial blood triglyceride levels were above 1,000 mg/dl (range 1,590-8,690 mg/dl). Besides the usual treatment of acute pancreatitis, heparin and/or insulin were administered intravenously in continuous infusion. Heparin dose was guided by usual parameters of blood coagulation, and insulin dose, by serial determinations of blood glucose. Pancreatic necrosis was demonstrated in 4 patients. Results: Serum triglyceride levels decreased to <500 mg/dl within 3 days in all cases. No complication of treatment was observed and all patients survived. Early and late complications of pancreatitis occurred in one patient. Conclusion: Administration of heparin and/or insulin is an efficient alternative to reduce triglyceride levels in patients with acute pancreatitis and hypertriglyceridemia