Síndrome de distrés respiratorio agudo en paciente con COVID-19 / Acute respiratory distress syndrome in patient with COVID-19 / Síndrome do desconforto respiratório agudo em um paciente com COVID-19

Resumen: Introducción: La enfermedad por coronavirus (COVID-19 coronavirus disease por sus siglas en inglés) es una emergencia sanitaria, y una de las complicaciones más temidas es el síndrome de distrés respiratorio agudo (SDRA) dada su elevada mortalidad. Caso clínico: Paciente masculino de 59 años con antecedente de hipertensión y tabaquismo, que inicia síntomas posteriores a contacto con portador asintomático de COVID-19 proveniente del extranjero. La sintomatología que presentó fue mialgias, artralgias, febrícula de 37.7 grados, posteriormente fiebre de 38.4 grados, disnea, fatiga y odinofagia. Acude a consulta y se hospitaliza, otorgando tratamiento con cloroquina, azitromicina y oseltamivir por cuatro días; se tomó de muestra para COVID-19. El paciente mostró aumento de trabajo respiratorio, se tomó radiografía de tórax con opacidades heterogéneas periféricas de ambos pulmones y se corroboró por tomografía de tórax imagen de vidrio despulido. Presentó disnea progresiva e hipoxemia requiriendo manejo avanzado de la vía aérea y se trasladó a la Unidad de Cuidados Intensivos Metabólicos donde se recibió con ventilación mecánica (VM), requiriendo sedación, analgesia, relajante muscular así como ventilación protectora. Se realizaron cambios de posición para evitar microatelectasias. Se obtuvo por cultivos Pseudomonas aeruginosa y Escherichia coli. El día 11 de estancia en la UCI se logró progresar ventilación mecánica hasta destete de ésta, y el paciente se egresó de dicho servicio 48 horas después. Conclusiones: El presente caso evidencia el progreso del daño pulmonar por COVID-19 causando falla respiratoria que requirió ventilación mecánica, el tratamiento crítico consistió en fortalecer la dinámica de calidad enfatizando monitoreo ventilatorio, hemodinámico y metabólico.

Abstract: Introduction: Coronavirus disease (COVID-19) is a health emergency and one of the most feared complications is acute respiratory distress syndrome (ARDS) due to its high mortality. Clinical case: A 59-year-old male patient with a history of hypertension and smoking, who begins to show symptoms after contact with an asymptomatic carrier of COVID-19 from abroad. The symptoms presented were myalgia, arthralgia, 37.7-degree fever, later 38.4-degree fever, dyspnea, fatigue and odynophagia. He went to the clinic and was hospitalized, being treated with chloroquine, azithromycin and oseltamivir for four days and a sample was taken for COVID-19. The patient presented increased respiratory work, chest radiography was taken with heterogeneous peripheral opacities of both lungs and was corroborated by chest tomography image of polished glass. He presented progressive dyspnea and hypoxemia requiring advanced airway management and was transferred to the metabolic intensive care unit where he was received with mechanical ventilation (MV), requiring sedation, analgesia, muscle relaxant, as well as protective ventilation. Changes of position were made to avoid micro atelectasis. It was obtained by culture of Pseudomonas aeruginosa and Escherichia coli. On the 11th day of the stay in ICU, mechanical ventilation was achieved until weaning, and the patient was discharged from ICU 48 hours later. Conclusions: The present case evidences the progress of lung damage by COVID-19 causing respiratory failure requiring mechanical ventilation, where the critical treatment consisted in strengthening the quality dynamics emphasizing ventilatory, hemodynamic and metabolic monitoring.

Resumo: Introdução: A doença por coronavírus (COVID-19 coronavirus disease, por sus siglas en inglés) é uma emergência de saúde, e uma das complicações mais temidas é a síndrome do desconforto respiratório agudo (SDRA), dada sua alta mortalidade. Caso clínico: Paciente do sexo masculino, 59 anos, com história de hipertensão e tabagismo, que iniciou os sintomas após contato com portador de COVID-19 assintomático do exterior. Os sintomas que apresentou foram mialgias, artralgias, febrícula de 37.7 graus, posterioriormente febre de 38.4 graus, dispnéia, cansaço e odinofagia, assiste a consulta médica e é hospitalizado, iniciando tratamento com cloroquina, azitromicina e oseltamivir durante 4 dias e foi uma colhida amostra por COVID-19. O paciente apresentava aumento do esforço respiratório, radiografia de tórax com opacidades periféricas heterogêneas de ambos pulmões e imagem em vidro fosco corroborada pela tomografia de tórax. Apresentou dispnéia progressiva e hipoxemia com necessidade de manejo avançado das vias aéreas e foi encaminhado para unidade de terapia intensiva metabólica onde recebeu ventilação mecânica (VM), necessitando de sedação, analgesia, relaxante muscular, além de ventilação protetora. Mudanças de posição foram feitas para evitar micro atelectasia. No cultivo obtivemos Pseudomonas aeruginosa e Escherichia coli. No 11 dia de internação na UTI, a ventilação mecânica foi progredida até o desmame, sendo dispensado do referido serviço 48 horas depois. Conclusões: O presente caso mostra a evolução do dano pulmonar por COVID-19 causando insuficiência respiratória que requer ventilação mecânica, onde o tratamento crítico consistiu no fortalecimento da dinâmica de qualidade com ênfase na monitoração ventilatória, hemodinâmica e metabólica.

Efecto de la aspirina en la mortalidad del síndrome de distrés respiratorio agudo en pacientes internados en la Unidad de Cuidados Intensivos del Hospital Juárez de México / Effect of aspirin on the mortality of acute respiratory distress syndrome in patients admitted to the Intensive Care Unit of the Juarez hospital in Mexico / Efeito da aspirina sobre a mortalidade na síndrome da angústia respiratória aguda em pacientes internados na unidade de terapia intensiva do Hospital Juárez de México

Resumen: Objetivo: Determinar el efecto en la morbimortalidad del uso de la aspirina después de 28 días en pacientes con SDRA. Material y métodos: Se realizó un ensayo clínico experimental, prospectivo aleatorizado simple durante el periodo comprendido del 01 diciembre de 2015 al 30 de junio de 2016 en la UCI del Hospital Juárez de México. Se incluyeron todos los pacientes que ingresaron a la UCI durante el periodo de estudio con diagnóstico de SDRA y se dividieron en dos grupos de manera aleatoria. Al grupo A se le administraron 100 mg de aspirina además del tratamiento estándar para SDRA y el grupo B sólo recibió tratamiento médico estándar para SDRA. Se cuantificaron los cambios en los valores de PaO2/FiO2, los valores de DA-aO2 y de Cstat, días de ventilación mecánica, así como la asociación de los valores del score APACHE II y su relación con la morbimortalidad en ambos grupos. Se utilizó la prueba estadística T de Student para variables independientes. Resultados: La mortalidad en el grupo A fue de 60% versus 80% en el grupo B. No se evidenció diferencia entre ambos grupos en la PaO2/FiO2 (p = 0.097). En el grupo A se observó una media de días de ventilación mecánica de 15.8 días versus 16.8 en el grupo B (p = 0.860, IC 95%), respecto a los días de estancia en la UCI y estancia intrahospitalaria no hubo diferencia estadísticamente significativa. Conclusiones: El uso de aspirina en pacientes con SDRA establecido, independientemente de su gravedad, no disminuye la mortalidad, ni acorta los días de estancia en la UCI o de estancia hospitalaria, como tampoco reduce los días de ventilación mecánica, ni mejora la PaO2/FiO2, la DAaO2 o la Cstat.

Abstract: Objective: To determine the effect on morbidity and mortality at 28 days with the use of aspirin in patients with ARDS. Material and methods: An experimental, prospective randomized clinical trial simply was conducted during the period from December 1, 2015 to June 30, 2016 in the ICU of Hospital Juarez of Mexico. all patients admitted to the ICU during the study period with a diagnosis of ARDS and were divided into two groups randomly included. Group A received 100 mg of aspirin in addition to standard treatment for ARDS, group B received only standard medical treatment for ARDS. changes in the values of PaO2/FiO2, the values of the DA-aO2 and CESTAT, days of mechanical ventilation, as well as the association of the values of APACHE II score and its relationship with morbidity and mortality in both groups were quantified. Statistical T Student test was used for independent variables. Results: Mortality in group A was 60% versus 80% in group B. No difference was observed in both groups in the PaO2/FiO2 (p = 0.097). In group A, an average of days of mechanical ventilation of 15.8 days versus 16.8 in group B (p = 0.860, 95%) compared to the days of stay in the ICU and hospital stay was found no statistically significant difference was observed. Conclusions: The use of aspirin in patients with ARDS established, regardless of severity; it does not decrease mortality, days of stay in the ICU or Hospital, nor diminish the days of mechanical ventilation, or improve PaO2/FiO2, the DAaO2, and CESTAT.

Resumo: Objetivo: Para determinar o efeito sobre a morbimortalidade aos 28 dias com o uso da aspirina em pacientes com SARA. Material e métodos: Realizou-se um ensaio clínico experimental, prospectivo randomizado simples, durante o período compreendido de 01 de dezembro de 2015 a 30 de junho de 2016 na UTI do Hospital Juárez do México. Foram incluídos todos os pacientes admitidos na UTI durante o período do estudo com um diagnóstico de SARA e foram divididos em dois grupos aleatoriamente. O Grupo A recebeu 100 mg de aspirina ademais do tratamento padrão para a SARA, o grupo B recebeu apenas o tratamento médico padrão para a SARA. Foram quantificados as alterações nos valores da PaO2/FiO2, valores DA-aO2 e Cestat, dias de ventilação mecânica, associação dos valores da pontuação APACHE II e a sua relação com a morbimortalidade em ambos os grupos. Se utilizou a prova estatística teste T Student para variáveis independentes. Resultados: A mortalidade no grupo A foi de 60% versus 80% no grupo B. Não se evidenciou diferença em ambos grupos na PaO2/FiO2 (p = 0.097). No Grupo A encontramos uma média de dias de ventilação mecânica de 15.8 dias versus 16.8 no grupo B (p = 0.860, IC 95%), com respeito aos dias de permanência na UTI e estadia hospitalar não observamos nenhuma diferença estatisticamente significativa. Conclusões: O uso da aspirina em pacientes com SARA estabelecido, independentemente da gravidade, não diminui a mortalidade, os dias de estadia na UTI e a estância hospitalar, assim como não diminui os dias de ventilação mecânica e não melhora a PaO2/FiO2, a DAaO2, e a Cestat.

Color doppler ultrasound study of the embolism and sclerotherapy of fibrin glue combined with bleomycin for the treatment of cervicofacial vascular malformations / 实用口腔医学杂志

Objective:To explore the mechanism of the embolism and sclerotherapy of fibrin glue combined with bleomycin (FG/BLM) for the treatment of cervicofacial vascular malformations by color doppler ultrasound.Methods:10 patients with venous malformation(VM) and 10 patients with arterio-venous malformation(AVM) were included.All patients underwent embolism and sclerotherapy of FG/BLM guided by ultrasound.Color doppler ultrasound was used to record the real-time two-dimensional ultrasonography and color doppler image.The flow and distribution of FG/BLM after injection into the lesions were observed.Results:Two-dimensional ultrasonography showed clumps or flake strong echo after immediate injection of FG/BLM into the cavity of VMs,then floated in the abnormal venous lumen and diffused throughout the cavity.At the later stage the lesions were filled by a large number of flocculent and netted low echo,and patchy strong echo.The volume of VMs cavity expanded dramaticlly,and the blood flow signal was significantly decreased.After injection of FG/BLM into the lumen of AVMs,clumps or flake strong echo were observed,then most of the snowflake strong echo rapidly filled or scattered along with blood stream to the distal part of the vessels.The color doppler showed significantly decrease of blood flow signal.Conclusion:FG/BLM injection can embolize and block the draining vein of VM,and play a role on the storage of sclerozing agent.FG/BLM injection can embolize both the dilated blood vessels and capillary network of AVM.

Cardiovascular responses with valsalva maneuver during activities of daily livings in healthy adults.

Purpose of Study: To measure CV responses in SLF, and SQ with & without VM, Study design: Cross sectional Observational study, Materials: assessment form, 36 SF Health Questionnaire, Modified Sphygmomanometer, BP apparatus, Nike-HRM-TRIAX, Methodology: 335 (M=146) subjects participated to perform SLF and SQ position with & without VM and SBP, DBP and HR were recorded. Data Analysis: SPSS -10.1, LOS was set at 0.05 or CI 95 %. Result: Study has shown significant increases in SBP in SQ and increase HR in SLF position with and without VM. Discussion: the impact of Heart Rate Variability and baroreflex sensitivity in CV system plays vital role in maintaining hemodynamic status while performing valsalva like activities. Conclusion: SQ has significant impact on SBP and DBP as compared to SLF position with and without VM as well as SLF position has a significant impact on HR as compared to SQ with VM, however these need to be taken into consideration while planning life style modification for high risk population.

Clinical Experiences about Correction of Web Space Contracture and Syndactyly using V-M Plasty

PURPOSE: The loss of web space is caused by congenital syndactyly or acquired burn injury, trauma or surgery. Numerous surgical procedures have been described for restoration of the web space. Local flaps are usually preferred because of the easiness to perform and tolerable postoperative outcome. Among the various local flaps, the authors introduce V-M plasty for correction of web space contracture and syndactyly. METHOD: From March 2007 to Jun 2008, 4 patients underwent V-M plasty for correction of web space contracture and syndactyly. V-M plasty consists of 3 distinct triangular flaps. One triangular flap is designed next to the web region on the dorsal site of the hand, whereas the remaining 2 triangular flaps are placed on the volar site. The dorsal triangular flap is then placed between the volar adjacent triangular flaps. At the end of the operation, the involved fingers or toes are positioned in abduction to avoid kinking of the triangular flaps. RESULT: All the patients gained web functions with good esthetic appearance without any recurrence or complications. Mean follow-up was 8 months. CONCLUSION: V-M plasty is a safe, easy and rapid procedure to design and apply by using local tissues without the needs for a skin graft or risk of linear scarring and recurrence. The authors advise this versatile technique both in primary and recurrent cases of web space contracture and syndactyly.