RESUMEN
Lung computed tomography (CT) is being used increasingly to assess lung morphology in patients on mechanical ventilation. Lung CT under known levels of airway pressure (dynamic CT) can also assess the response of lung parenchyma to ventilatory therapy. We report a patient with acute respiratory distress syndrome secondary to descending necrotizing mediastinitis, in whom lung dynamic CT oriented ventilatory management. Independent lung ventilation improved gas exchange and helped patient recovery
Asunto(s)
Humanos , Masculino , Adulto , Mediastinitis , Síndrome de Dificultad Respiratoria/etiología , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/terapia , Tomografía Computarizada por Rayos X/métodosRESUMEN
Cardiopulmonary extracorporeal assistance is a high complexity procedure for patients with acute respiratory failure, who have failed conventional ventilatory support. A 30 years old female patient with bacterial endocarditis and congestive cardiac failure subjected to cardiac surgery presented severe hypoxemia, right heart failure and pulmonary hypertension, and failed conventional treatment. Cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) reverted the pathophysiologic alterations allowing a successful recovery
Asunto(s)
Humanos , Adulto , Femenino , Endocarditis , Circulación Extracorporea/métodos , Síndrome de Dificultad Respiratoria/cirugía , Enfermedades Reumáticas/complicaciones , Insuficiencia de la Válvula Mitral/cirugía , Reanimación Cardiopulmonar/métodosRESUMEN
Traditionally Pulmonary wedge pressure (PWP) determination with Swan-Ganz catheter has been the gold standard to estimate ventricular preload in critically ill patients. However, the correlation between PWP and left ventricular telediastolic volume is poor, and the tecnique does not allow any estimation of extravascular lung water (EVLW). In the last years, several techniques have been developed to improve assessment of intra and extravascular volumes. Two tracers transcardiopulmonary dilution method was developed by Pearce et al in the early 60ïs. It used a thermal tracer to estimate intrathoracic total volumen (ITTV), and a colorimetric tracer for estimting intrathoracic blood volume (ITBV). The difference between ITTV and ITBV is called EVLW. Recently, the technique has been simplified to use just the thermal tracer. The Pulse Contour Cardiac Output computer (PiCCO, Pulsion Medizintechnik, Germany), allows a continous measurement of cardiac output and an intermittent measurement of ITTV, ITBV and EVLW. The use of this new technique could improve patient management, allowing optimal fluids administration without producing lung edema. Besides the PiCCO computer, both a standard central venous line in an upper body vein and a specially designed femoral artery line to measure thermal tracer dissipation are required. Preliminary experience has shown that it is a reliable method, with low morbidity and easy implementation, and may be a promising and useful tool in critical care patients
Asunto(s)
Humanos , Agua Pulmonar Extravascular , Volumen Sanguíneo/fisiología , Presión Sanguínea , Gasto Cardíaco , Cateterismo de Swan-Ganz , Termodilución/métodosRESUMEN
Splanchnic hypoperfusion, with pathogenic implications for multiple organ failure, can occur during septic shock. We report four patients with septic shock in whom regional hepatosplenic splanchnic perfusion was monitored through suprahepatic vein catheterization and gastric tonometry. Suprahepatic lactate and oxygen saturation showed splanchnic hypoperfusion in all patients. These parameters improved only in the patient that survived. Gastric tonometry was more inconsistent. We conclude that suprahepatic vein catheterization could have a role in the management of septic shock
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Cateterismo , Choque Séptico/terapia , Manometría , Insuficiencia Multiorgánica/complicaciones , Circulación Esplácnica/fisiología , Choque Séptico/etiología , Venas HepáticasRESUMEN
Ventilator-associated pneumonia is a life-threatening disease causing an increased morbidity, cost and length of stay in the intensive care unit. This document is an evidence based consensus which discusses preventive measures including medical recommendations and practices for cleaning and handling mechanical ventilators. Standard and contact precautions are critical preventive measures
Asunto(s)
Humanos , Neumonía/prevención & control , Respiración Artificial/efectos adversos , Profilaxis Antibiótica , Esterilización/métodos , Hemorragia Gastrointestinal , Intubación Intratraqueal/métodos , Neumonía/etiología , Factores de RiesgoRESUMEN
Quisimos evaluar la aplicabilidad y eficacia de la ventilación con presión positiva no invasiva (VPPNI) en pacientes con insuficiencia respiratoria aguda (IRA) hipoxémica y aumento del trabajo respiratorio. En un periodo de 10 meses evaluamos a 64 pacientes que ingresaron a nuestro servicio con el diagnóstico de IRA y signos de fatiga muscular, en ausencia de patología crónica. Fueron considerados no aptos para VPPNI quienes tuvieran compromiso de conciencia importante, inestabilidad hemodinámica o más de dos órganos en falla, cirugía reciente de esófago, estómago o duodeno, hemorragia digestiva alta activa, distensión abdominal importante o dificultad en el manejo de secreciones. Luego de aplicar los criterios de exclusión, 14 (23 por ciento) pacientes fueron sometidos a VPPNI por un periodo de 1 a 9 días. La Pa/FiO2, sin cambios significativos en la PaCO2 y frecuencia respiratoria. En 5 pacientes (36 por ciento) fracasó el método, de los cuales 2 fallecieron. Un paciente presentó una escara nasal. Por su mínima invasividad y fácil aplicación, la VPPNI debe ser considerada precozmente en todo paciente con IRA hipoxémica con buen nivel de conciencia y que preserve su ventilación espontánea
Asunto(s)
Humanos , Masculino , Femenino , Respiración Artificial/métodos , Insuficiencia Respiratoria/terapia , Ventilación con Presión Positiva Intermitente/métodos , Hipoxia/terapia , Ventilación con Presión Positiva Intermitente/instrumentaciónRESUMEN
Background: Amphotericin B is efficacious for the treatment of systemic candidiasis, however it has potentially serious toxic effects. Administration as lipid emulsions has been advocated to decrease its toxicity. Aim: To compare the safety and tolerance of amphotericin B administered as lipid emulsion or dissolved in dextrose in water. Patients and methods: Forty five patients with confirmed or highly suspected systemic candidiasis were studied. Between January 1996 and June 1997 amphotericin B was administered in dextrose in water to 17 patients (group 1). Between July 1997 and December 1998, the drug was delivered in lipid emulsions (Intralipid, group 2). Clinical and laboratory parameters (serum creatinine, urea nitrogen and potassium), were assessed daily. Results: Both treatment groups were clinically comparable and had the same survival. Accumulative amphotericin B dose administered was 343.2 ñ 197 and 414.6 ñ 518 mg respectively. Hypokalemia was more frequent in group 2 (52 and 25 percent respectively, p < 0.05). There were no differences in the outcome of renal function or other adverse reactions. Conclusions: Administration of amphotericin B as lipid emulsions did not reduce its toxicity in critical patients
Asunto(s)
Humanos , Femenino , Masculino , Adulto , Persona de Mediana Edad , Candidiasis/tratamiento farmacológico , Anfotericina B/farmacología , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/prevención & control , Candida/aislamiento & purificación , Candida/efectos de los fármacos , Anfotericina B/administración & dosificación , Anfotericina B/efectos adversos , Tolerancia a Medicamentos , Hipopotasemia/inducido químicamente , Enfermedad CríticaRESUMEN
Background: in 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions. Aim: to evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS. Patients and methods: five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient. Results: One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48 percent in sepsis compared to 43 and 51 percent in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group. Conclusions: The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies
Asunto(s)
Humanos , Masculino , Femenino , Adolescente , Adulto , Persona de Mediana Edad , Sepsis/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Peritonitis/complicaciones , Sepsis/etiología , Bacterias Gramnegativas/patogenicidad , Unidades de Cuidados Intensivos , Evolución Clínica , Neumonía/complicaciones , Pronóstico , Síndrome de Respuesta Inflamatoria Sistémica/etiologíaRESUMEN
Background: Acute brain injury is associated with a bimodal hypermetabolic state probably caused by cytokine secretion and high hormone and catecholamine concentrations. In a first stage, the brain would produce these substances and afterwards, another production source, most probably the splanchnic territory, would perpetuate the hypermetabolic state. Aim: To investigate the cytokine production source and to assess intestinal permeability in acute brain injury in the absence of cerebral ischemia and systemic oxygen deficit. Patients and methods: Arterial systemic and cerebral venous bulbar interleukin 1 õ and interleukin 6 levels were measured during the first seven days of evolution in 15 patients with acute brain injury. Serum lactate, the oxygen/lactate ratio, gastric intramucosal pH and intestinal permeability using the lactulose/mannitol test were also assessed in the same period. Results: High arterial and venous interleukin 1 õ and interleukin 6 levels were detected. A positive gradient for interleukin 6 levels was detected throughout the study period with normal intramucosal pH, lactate and oxygen/lactate ratio. There was also an early impairment of intestinal permeability in these patients. Conclusions: High arterial and venous cytokine concentrations were detected in patients with acute brain injury. The positive gradient for interleukin 6 suggests a brain origin for this cytokine. Intestinal permeability is also altered in these patients
Asunto(s)
Humanos , Femenino , Masculino , Persona de Mediana Edad , Lesiones Encefálicas/metabolismo , Citocinas , Interleucina-6/metabolismo , Interleucina-1/metabolismo , Lactulosa/administración & dosificación , Manitol/administración & dosificaciónRESUMEN
Background: Vasoactive drugs used in the reanimation of septic patients, can modify splanchnic perfusion. Aim: To compare the effects of dobutamine and amrinone on gastric intramucosal pH (pHi), lactate levels and hemodynamics in surgical patients with compensated septic shock. Patients and methods: Fourteen postoperative patients with abdominal sepsis and compensated septic shock (pHi <7.32 or lactate >2.5 mmol/l) were studied in a prospective, randomized, unblinded study. Patients were randomized to receive (Group 1, n=7) dobutamine at 5 µg/Kg/min or (Group 2, n=7) amrinone at 5 µg/Kg/min. Hemodynamic data, arterial lactate and pHi were measured before and 30, 60 and 120 minutes after starting drug infusion. Results: Both drugs were associated with a decrease in lactate levels. Dobutamine infusion, but not amrinone, increased gastric pHi, as well as cardiac index and oxygen delivery. Conclusions: An improvement in gastric pHi associated with an increase in oxygen delivery, was observed with dobutamine. Amrinone showed no effect at the fixed, low dose used in the study
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Amrinona/farmacología , Dobutamina/farmacología , Choque Séptico/tratamiento farmacológico , Complicaciones Posoperatorias/tratamiento farmacológico , Abdomen Agudo/cirugía , Lactatos/metabolismo , Lactatos/sangre , Circulación Esplácnica , Concentración de Iones de Hidrógeno , Choque Séptico/etiologíaRESUMEN
Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intestinal permeability, derangement in mucosal barrier functions and translocation of proinflammatory mediators. These changes can contribute to the pathogenesis of multiple organ failure. Vasoactive drugs such as dobutamine and dopexamine can improve splanchnic perfusion and gastric intramucosal pH during sepsis. However, contradictory results have been obtained with dopamine and norepinephrine. On the other hand, epinephrine further impairs splanchnic perfusion. In view of the contradictory effects of different vasoactive drugs, gastric tonometry must be measured during their use, to find the optimal drug combination that optimizes splanchnic blood flow
Asunto(s)
Catecolaminas/farmacología , Sepsis/complicaciones , Circulación Esplácnica , Catecolaminas/clasificación , Dopamina/farmacología , Norepinefrina/farmacología , Dobutamina/farmacología , Concentración de Iones de Hidrógeno , Choque SépticoRESUMEN
Patients with severe head injury are prone to pulmonary complications that result in hypoxemia or hypercarbia, which could worsen their neurological condition. A rational ventilatory approach requires a good knowledge of respiratory and neurological pathophysiology. Airway management is of prime importance in neurological patients. Prophylactic chronic hyperventilation in head trauma is no longer recommended since it could impair cerebral perfusion, although transient hypocarbia could be of benefit to some patients. The use of low or moderate positive and expiratory pressure levels apparently improves oxygenation without worsening intracranial pressure. Ventilatory management should be closely monitored and adjusted to hemodynamic, respiratory and neurological status to achieve a good outcome
Asunto(s)
Enfermedades del Sistema Nervioso Central/terapia , Respiración Artificial/métodos , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/terapia , Desconexión del Ventilador , Enfermedades del Sistema Nervioso Central/complicaciones , Hiperventilación/etiología , Hiperventilación/fisiopatología , Enfermedades Pulmonares/etiologíaAsunto(s)
Humanos , Insuficiencia Multiorgánica/complicaciones , Sepsis/complicaciones , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/fisiopatología , Óxido Nítrico/farmacología , Sepsis/diagnóstico , Sepsis/etiología , Sepsis/fisiopatología , Sepsis/terapia , Choque Séptico/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/diagnósticoAsunto(s)
Humanos , Insuficiencia Multiorgánica/complicaciones , Choque Séptico/complicaciones , Síndrome de Respuesta Inflamatoria Sistémica/complicaciones , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/epidemiología , Insuficiencia Multiorgánica/fisiopatología , Sepsis/etiología , Choque Séptico/diagnóstico , Choque Séptico/fisiopatología , Choque Séptico/historia , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/fisiopatologíaAsunto(s)
Humanos , Microcirculación/fisiología , Oxigenación , Choque Séptico/fisiopatología , Ácido Láctico , Acidosis Láctica/etiología , Acidosis Láctica/tratamiento farmacológico , Concentración de Iones de Hidrógeno , Manometría , Insuficiencia Multiorgánica/fisiopatología , Transferencia de Oxígeno , Reanimación Cardiopulmonar , Sepsis/terapia , Choque Séptico , Circulación EsplácnicaAsunto(s)
Humanos , Insuficiencia Multiorgánica/metabolismo , Síndrome de Dificultad Respiratoria del Recién Nacido/etiología , Sepsis/metabolismo , Síndrome de Respuesta Inflamatoria Sistémica/metabolismo , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/tratamiento farmacológico , Lesión Renal Aguda/etiología , Encefalopatías Metabólicas/diagnóstico , Coagulación Intravascular Diseminada , Necrosis Tubular Aguda/etiología , Infecciones Meningocócicas , Pancreatitis/diagnóstico , Pancreatitis/etiología , Pulmón/fisiopatología , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológicoAsunto(s)
Humanos , Insuficiencia Multiorgánica/terapia , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Síndrome de Respuesta Inflamatoria Sistémica/terapia , Adyuvantes Inmunológicos/farmacología , Agua Corporal/fisiología , Permeabilidad Capilar , Coloides/farmacología , Hemofiltración , Necesidades Nutricionales , Respiración Artificial , Reanimación Cardiopulmonar , Síndrome de Respuesta Inflamatoria Sistémica/tratamiento farmacológico , Equilibrio HidroelectrolíticoRESUMEN
La carencia de donantes oportunos en casos de insuficiencia hepática aguda fulminante (IHAF) requiere contar con sistemas de soporte hepático transitorio. Para ensayarlos antes de su uso clínico es necesario tener modelos animales de IHAF estandarizados y reproducibles. Nuestro objetivo fue establecer un modelo canino de IHAF por intoxicación oral con acetaminofeno (ACE), para obtener una necrosis hepática (NH) superior al 60 por ciento y determinar los cambios en diferentes variables bioquímicas susceptibles de ser corregidas en modelos de soporte hepático. Para ello se utilizaron 22 perros a los cuales se les administró ACE por sonda gástrica en 3 grupos (Gr): A: 500 mg/kg (n= 5), B: 750 mg/kg (n= 10) y C: 1000 mg/kg (n= 7). En ellos se determinaron los valores basases de diferentes variables bioquímicas de función hepática. Los animales fueron observados clínicamente, y entre las 22 y 24 h post-intoxicación (po.i.) se realizó una 2º determinación de los mismos parámetros en los perros que sobrevivieron. Finalmente se realizó una biopsia hepática, y en los perros fallecidos una necropsia. Se analizó el grado de NH obtenida, su relación con la mortalidad y los resultados de las variables bioquímicas pre y po.i. con diferentes pruebas estadísticas. Resultados: Sobrevivieron 19 animales al procedimiento basal. De ellos, en 10 (52,6 por ciento) se obtuvo una NH >60 por ciento (0, 56 y 83 por ciento de los Gr A, B y C respectivamente, p< 0,05). El 80 por ciento de estos animales (5/6 del Gr C y 319 del Gr B) falleció entre las 14 y 26 h po.i. posterior a un cuadro clínico y bioquímico de falla hepática aguda. En 3 animales no se observó NH, todos del Gr A. No falleció ningún animal con NH < 60 por ciento (p< 0,01). El análisis de las variables bioquímicas pre y po.i. mostró un trastorno metálico importante en todos los animales intoxicados, dosis dependiente, con una mayor sensibilidad para los cambios en los niveles de bilirrubina y transaminasas. En conclusión, con dosis entre 750 y 1000 mg/kg de ACE oral se establece un modelo canino de 1 HAF válido para ser utilizado en la evaluación de sistemas de soporte hepático transitorio