Reunión clínica inter-hospitales: hipertensión arterial y microangiopatía trombótica en lupus eritematoso sistémico / Inter-hospital clinical meeting: hypertension and thrombotic microangiopathy in systemic lupus erythematosus

Se presenta una paciente portadora de lupus eritematoso sistémico (LES), descompensado por múltiples factores, que desarrolló una nefropatía lúpica e hipertensión arterial severa de difícil manejo, asociadas a disfunción orgánica múltiple y microangiopatía trombótica, tratadas con plasmaféresis e inmunosupresión. Se exponen las causas y mecanismos fisiopatológicos más importantes de la hipertensión arterial (HTA) severa en pacientes con LES. Enseguida se analizará específicamente el púrpura trombocitopénico trombótico como causa y/o efecto de HTA en LES.

We present a patient with systemic lupus erythematosus (SLE), outweighed by multiple factors, who developed lupus nephritis and severe hypertension difficult to handle, associated with organ dysfunction and thrombotic microangiopathy treated with plasmapheresis and immunosuppression. This document explains the causes and pathophysiological mechanisms leading to hypertension (HT) in patients with severe SLE. Then specifically analyzed as thrombotic thrombocytopenic purpura cause and / or effect of hypertension in SLE.

Reunión clínica inter-hospitales: síndrome antifosfolípidos catastrófico, un cuadro de microangiopatía / Catastrophic antiphospholipid syndrome, a case of microangiopathy

Se presenta el caso de una mujer joven, sin antecedentes de importancia, que muestra trombosis de grandes y pequeños vasos. A pesar del tratamiento con anticoagulación y corticoides en dosis altas, desarrolla necrosis cutánea y una importante respuesta inflamatoria sistémica con disfunción orgánica múltiple, por lo que .se le indicó plasmaféresis y, posteriormente, rituximab, con buena respuesta. Se discute el síndrome antifosfolípidos con énfasis en los anticuerpos antiprotrombina y la patogenia de la microangiopatía en el síndrome antifosfolípidos catastróficos.

We present the case of a young, otherwise healthy woman, who developed thrombosis of large and small vessels and capillaries. Despite anticoagulation treatment and high doses of glucocorticoids, she developed cutaneous necrosis and systemic inflammatory response with multiple organ dysfunction. Plasmapheresis and rituximab were administered with good response. We discuss the antiphospholipid syndrome, with emphasis on antiprothrombin antibodies and the pathogenesis of microangiopathy in antiphospholipid syndrome.

Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica / Protocol based sedation versus conventional treatment in critically ill patients on mechanical ventilation

Background: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. Aun: To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). Material and methods: Inclusión criteria was the need of MV more than 48 h. The exclusión criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. Results: Forty patients were included, 22 aged 65±19 years in group P and 18 aged 54±21 years in group C. Apache II scores were 16±8 and 19±8 in each group. SAS score was more frequently evaluated within goal boundaries in group P than in group C (44 percent and 32 percent, respectively p =0.001). No differences in the proportion of patients with inadequate sedation were observed between treatment groups. Midazolam doses were lower in P than in C group (0.04 (0.02-0.07) and 0.06 (0.03-0.08) mg/kg/h respectively, p =0.005). Conclusions: The implementation of sedation protocol applied by nurses improved the quality of sedation and reduced the doses of Midazolam in mechanically ventilated patients.