Actualización del bundle de reanimación inicial y monitorización integral de la perfusión tisular en la sepsis severa / Initial resuscitation bundle and monitoring tissue perfusion in severe sepsis

Sepsis is a global health problem. Despite recent advances in understanding its pathophysiology and clinical trials testing potential new therapies, mortality remains unacceptably high. In fact, sepsis is the leading cause of death in non-coronary intensive care units around the world. However, during the past decade, some studies have highlighted that early recognition of sepsis and an appropriate initial approach are fundamental determinants of prognosis. A systematic approach to the harmful triad of sepsis-related hypotension, tissue hypoperfusion and organ dysfunction, with low-cost, easy to implement, and effective interventions, can significantly improve the chances of survival. In this article, we will update the evidence supporting the initial resuscitation bundle for patients with severe sepsis, and discuss the physiological basis for perfusion monitoring during septic shock resuscitation.

Manejo del paciente en shock séptico / Management of the septic shock patient

El shock séptico es la manifestación más grave de una infección. Esta se produce como consecuencia de una respuesta inflamatoria sistémica severa que lleva a un colapso cardiovascular y/o microcirculatorio, y a hipoperfusión tisular. La hipoperfusión constituye el elemento central que define la condición de shock y esta debe ser detectada y revertida en forma urgente desde la atención inicial. La evaluación de la perfusión periférica, la diuresis, y la medición del lactato y de la saturación venosa central, son las principales herramientas para evaluar la perfusión sistémica. La reanimación debe comenzar en forma inmediata con la administración agresiva de fluidos, la cual puede ser guiada por parámetros dinámicos de respuesta a fluidos, y continuada hasta normalizar u optimizar las metas de perfusión. En forma paralela se debe iniciar vasopresores en caso de hipotensión marcada, siendo el agente de elección noradrenalina, y conectar precozmente al paciente a ventilación mecánica frente a hipoperfusión severa que no responde a fluidos, o frente a un aumento del trabajo respiratorio. Adicionalmente, el foco infeccioso debe ser tratado agresivamente iniciando antibióticos lo antes posible.

Septic shock is the most severe manifestation of an infection. It is caused by a systemic inflammatory response syndrome, which leads to cardiovascular and/or microcirculatory failure, and to tissue hypoperfusion. Hypoperfusion is the most important feature, which defines the shock state, and which must be detected and treated urgently from the very first attention. Peripheral perfusion, urine output, and lactate and central venous saturation measurements, are the main tools to assess systemic perfusion. Resuscitation must start immediately with fluid administration, which can be guided by dynamic predictors of fluid responsiveness, and continued until normalizing or optimizing perfusion goals. In the presence of hypotension, vasopressors should be started in parallel, with noradrenaline being the preferred option. If hypoperfusion persists, or if respiratory work is too high, mechanical ventilation should be started promptly. In addition, infection should be treated aggressively starting antibiotics as soon as possible.

Hipotermia intravascular inducida en el manejo de la hipertensión intracraneana en insuficiencia hepática aguda: caso clínico / Intravascular hypothermia for the management of Intracranial hypertension in acute liver failure: case report

Acute liver failure has a mortality rate in excess of 80 percent. Most deaths are attributed to brain edema with intracranial hypertension and herniation of structures, where ammonium plays a major role in its generation. We report an 18 year-old female with a fulminant hepatic failure caused by virus A infection. The patient developed a profound sopor and required mechanical ventilation. A CT scan showed the presence of brain edema and intracranial hypertension. A Raudemic® catheter was inserted to measure intracranial pressure and brain temperature. Intracranial hypertension became refractory and intravascular hypothermia was started, reducing brain temperature to 33°C. Seventy two hours later, a liver transplantation was performed. After testing graft perfusion, rewarming was started, completing 122 hours of hypothermia at 33°C. The patient was discharged in good conditions after 69 days of hospitalization.

Evaluación de la microcirculación sublingual en un paciente en shock séptico refractario tratado con hemofiltración de alto volumen / Evaluation of sublingual microcirculation in septic shock: report of one patient treated with high volume hemofiltration

Microcirculation is severely compromised in sepsis, with a reduction of capillary density and flow impairment. These alterations have important prognostic implications, being more severe in non-survivors to septic shock. Today microcirculation may be assessed bedside, non-invasively usingpolarized light videomicroscopy a technique known as SDF (side dark field). We report a 54 year-old man with an extramembranous nephropathy that developed a necrotizing fascitis associated to septic shock, in whom microcirculation was periodically assessed during his management. The patient was treated with Buids, vasoactive drugs, antibiotics and was operated for exploration and debridement. As the patient persisted in refractory shock despite treatment, high-volume hemofiltration was started. Before hemofiltration the patient had severe microcirculatory alterations that improved during and after the procedure. Physiologic endpoints of high-volume hemofiltration in septic shock remain unknown, but it has the capacity to clear inflammatory mediators. Since microcirculatory alterations are in part secondary to these mediators, their removal is beneficial. Like other authors, we found no relation between microcirculation and other haemodynamic and perfusion variables.

Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: Primer estudio nacional multicéntrico / Prevalence of severe sepsis in Intensive Care Units: A national multicentric study

Background: Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). Aim: To study the prevalence of SS in Chilean ICUs. Material and methods: An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Results: Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66 percent. Mean age of patients was 57.7+18 years and 59 percent were male, APACHE II score was 15+7.5 and SOFA score was 6+4. SS was the admission diagnosis of 94 of the 283 patients (33 percent) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40 percent). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9 percent (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7 percent (30/112) and 8.7 percent (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48 percent respiratory and 30 percent abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. Conclusions: SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APA CHE II and SOFA scores were independent predictors of mortality.

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional / Mechanical ventilation in patients with acute neurological disease: Survival and functional outcome

Background: The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign. Aim: To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation. Patients and methods: Prospective study of 77 patients (42 men, age 54±19 years, with 11±4 points of Glasgow coma scale (GCS), 61 percent with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index. Results: Thirty percent of patients died during follow up. Among surviving patients, 47 percent had a good recovery or moderate disability, and 74 percent had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis. Conclusions: Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients (Rev Méd Chile 2004; 132: 11-8).

Síndrome nefrótico en artritis reumatoidea tratada con penicilamina / Penicillamine- induced nephrotic syndrome

Presentamos un caso de Artritis Reumatoídea seronegativa, tratada con Penicilamina durante 11 meses desarrollando un Síndrome Nefrótico a lesiones mínimas, que remite espontáneamente a los dos meses de suspendida la droga