Evaluación de la microcirculación sublingual en un paciente en shock séptico / Sublingual microcirculation asessment in a patient with septic shock

Introduction: Septic shock involves a complicated network of circulatory, inflammatory and metabolic disturbances,leading to cellular energetic disruption. Microcirculatory alterations are frequently observed in septic shock, being characteristic the presence of weak microcirculatory units and heterogeneous microcircu-latory flow. Clinical case: A female patient, two months of age, with a pulmonary process-originated septic shock is presented. The description of microcirculation alterations at 24, 72 and 120 hrs was performed while the patient underwent therapy. A MicroScan®, (MicroVision Medical, Amsterdam, Holland) was utilised on the sublingual area. The patient received ventilation support, reanimation fluids, vasoactive drugs and antibiotics. The patient presented low proportion of perfused capillary vessels, low ratio of microcirculatory flow and a high heterogeneity in flow in the first measurement, all of them independant from systemic hemodynamics and disoxia indicators. These severe alterations improved progressively at 72 and 120 hrs of therapy. Discussion: Microcirculatory alterations and its time evolution may be a tool for dynamic diagnostic and severity staging assesment in septic shock. Further studies should assess microcirculation as a target for therapeutic intervention (microcirculatory resuscitation), being also of prognostic value for septic shock and severe sepsis in children.

Introducción: El shock séptico involucra una compleja red de alteraciones circulatorias, inflamatorias y metabólicas que conducen a una disrupción energética celular. En el shock séptico se observan frecuentemente alteraciones microcirculatorias, siendo característico la existencia de unidades microcirculatorias débiles y un flujo microcirculatorio heterogéneo. Caso clínico: Se presenta una paciente de dos meses de edad con shock séptico de foco pulmonar, en la que realizamos una descripción de las alteraciones microcirculatorias a las 24, 72 y 120 h durante su tratamiento. Se utilizó MicroScan®, (MicroVision Medical, Amsterdam, Holanda) en el área sublingual. La paciente recibió soporte ventilatorio, fluidos de reanimación, drogas vasoactivas y antibióticos. En la medición inicial la paciente presentaba una baja proporción de capilares perfundidos, un bajo índice de flujo microcirculatorio y una alta heterogeneidad de flujo, todas ellas con independencia de la hemodinamia sistémica e indicadores de disoxia. Estas alteraciones graves mejoraron progresivamente a las 72 y 120 h de tratamiento. Discusión: Las alteraciones microcirculatorias y su evolución temporal pueden ser una herramienta diagnóstica dinámica y de estratificación de gravedad en estados de shock séptico. En estudios futuros la microcirculación deberá ser evaluada como un objetivo de intervención terapéutica (resucitación microcirculatoria) presentando a su vez un rol pronóstico en el shock séptico y sepsis grave en niños.

Gastrectomía vertical laparoscópica transumbilical / Transumbilical sleeve gastrectomy: experience in six patients

Background: The transumbilical route can be used to perform sleeve gastrectomies. Aim: To report the experience with transumbilical sleeve gastrectomy. Material and Methods: A prospective protocol of transumbilical sleeve gastrectomy was applied among patients with a body mass index of 36 kg/m² or less, and a distance between the xiphoid process and the umbilicus of less than 22 cm. Results: Six female patients, with a body mass index between 32.5 and 35.3 kg/m² have been operated. The operative time ranged from 90 to 170 min. An additional 5 mm trochar was required in the first two patients. The postoperative barium swallow showed a good distal passage and the absence of stenosis, residual fundus or nitrations in all patients. No patient had complications. Conclusions: Transumbilical sleeve gastrectomy is feasible among patients with a body mass index of less than 36 kg/m².

Introducción: La cirugía laparoscópica ha estado orientada los últimos años a buscar otras alternativas mínimamente invasivas de acceso abdominal. La transumbilical es una vía que ha comenzado a ser aplicada clínicamente, con o sin dispositivos de acceso único. Hemos comenzado a realizar la gastrectomía vertical laparoscópica (GVL) por vía transumbilical, en ciertos casos seleccionados. Objetivo: Evaluar la factibilidad de realizar la GVL por vía transumbilical, utilizando un dispositivo de acceso único y el resto del instrumental laparoscópico tradicional. Método: Protocolo prospectivo aplicado a pacientes que cumplan con criterios de inclusión como: ser candidato a GVL, tener IMC igual o menor a 36 kg/m², distancia entre apéndice xifoides y ombligo menor a 22 cm. El peso promedio de las pacientes operadas fue de 90,5 kg, (82,5-98), IMC promedio de 33,8 kg/m² (32,5-35,3). Se describe la técnica de inserción del dispositivo, de la gastrectomía y del manejo postoperatorio. Resultados: Se logró realizar GVL en las 6 pacientes en las que se intentó. El tiempo operatorio promedio fue de 127 min (90 a 170 min), en las dos primeras pacientes se requirió el uso de un trocar adicional de 5 mm. En todas las pacientes, la radiografía baritada de esófago, estómago y duodeno mostró buen paso a distal y ausencia de estenosis, fondo residual o filtraciones. No hubo morbilidad en este grupo. Conclusiones: La GVL es factible de realizar en pacientes portadores de obesidad menor a 36 kg/ m²de superficie corporal, usando un dispositivo de acceso único e instrumental laparoscópico tradicional.

Diez mitos sobre el retiro de la ventilación mecánica en enfermos terminales / Ten myths about withdrawal of mechanical ventilation in terminal patients

The most difficult of treatment limitation decisions, both for physicians and families, is the withdrawal of mechanical ventilation (MV). Many fears and uncer-tainties appear in this decision. They are described as “ten myths” whose falseness is argued in this article. The myths are: 1) Withdrawing MV causes the patient’s death; 2) Withdrawing MV is euthanasia; 3) Withholding and withdrawing MV are morally different; 4) MV can be withdrawn only when the patient has asked for it; 5) Chilean law only authorizes to withdraw VM when brain death has occurred; 6) Withdrawing MV cannot be done if the patient is not an organ donor; 7) Physicians who withdraw MV are in high risk of legal claims; 8) To withdraw MV the physician needs an authorization from the hospital ethics committee, lawyer or institutional authority; 9) There is only one way to withdraw MV; 10) Withdrawing MV produces great suffering to the patient’s family. Making clear that these myths are false facilitates appropriate decisions, therefore preventing “therapeutic obstinacy” and more suffering of terminally ill patients, which favors their peaceful death. For the physician this goal should be as rewarding as preventing the death of a curable patient.

Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus: Caso clínico / Addition of an arterio-venous shunt during veno-arterial extracorporeal life support in a patient with Hantavirus pulmonary syndrome

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

Volumen sanguíneo intratorácico versus presión arterial de oclusión pulmonar como estimadores de precarga cardíaca en pacientes críticos / Intrathoracic blood volume versus pulmonary artery occlusion pressure as estimators of cardiac preload in critically ill patients

Background:Monitoring of cardiac preload by determination of pulmonary artery occlusion pressure (PAOP) has been traditionally used to guide fluid therapy to optimize cardiac output (CO). Since factors such as intrathoracic pressure and ventricular compliance may modify PAOP, volumetric estimators of preload have been developed. The PiCCO system is able to measure CO and intrathoracic blood volume (ITBV) by transpulmonary thermodilution. Aim: To compare a volumetric (ITBV) versus a pressure (PAOP) determination to accurately estimate cardiac preload in severely ill patients. Patients and Methods: From June 2001 to October 2003, 22 mechanically ventilated patients with hemodynamic instability underwent hemodynamic monitoring with pulmonary artery catheter (PAC) and PiCCO system. ITBV index (ITBVI), PAOP and CI were measured simultaneously by both methods. One hundred thirty eight deltas (D) were obtained from the difference of ITBVI, PAOP, CI-PAC and CI-PiCCO between 6-12 am and 6-12 pm. Linear regression analysis of DITBVI versus Ð CI-PiCCO and Ð PAOP versus DCI-PAC were made. Results: Mean age of patients was 60.8 ± 19.4 years. APACHE II was 23.9 ± 7. Fifteen patients met criteria for acute respiratory distress syndrome (ARDS). Delta ITBVI significantly correlated with DCI-PiCCO (r=0.54; 95% confidence interval = 0.41-0.65; p <0.01). There was no correlation between DPAOP and Ð CI-PAC. Conclusion: ITBVI correlated better with CI than PAOP, and therefore it seems to be a more accurate estimator of preload in unstable, mechanically ventilated patients.

Fractura bronquial / Bronchial fracture

El traumatismo torácico es una entidad patológica emergente, relacionada con accidentes automovilísticos. La lesión más frecuente es la fractura costal. Dependiendo de su gravedad, éste puede provocar tórax volante, contusión cardíaca, lesiones vasculares u otras alteraciones. La ruptura bronquial se observa ocasionalmente en traumatismos torácicos cerrados, y por lo general tiene lugar en el tronco del árbol tráqueo-bronquial. Su diagnóstico y manejo inicial representan un problema mayor. Los signos clásicos son la persistencia de neumotórax y flujo masivo de aire a través del drenaje torácico: sin embargo también hay casos que no son típicos. Es difícil determinar el momento correcto para iniciar la ventilación con presión positiva, la que puede aumentar gravemente el flujo de aire a través de la ruptura bronquial y acentuar el neumotoráx a tensión. Presentamos el caso de un hombre de 25 años con un traumatismo torácico cerrado, causado por un accidente de automóvil, en quien la broncoscopía demostró una fractura del bronquio lobar medio. Comprobamos en este paciente, que la fibrobroncoscopía es el procedimiento más útil tanto en el diagnóstico, como en el tratamiento inicial y en el seguimiento post operatorio de su fractura bronquial.

Trasplante hepático en adultos: casuística de Clínica Alemana de Santiago / Adult liver transplantation: a single center experience from Chile

Background: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. Aim: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. Patients and methods: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. Results: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extra-hepatic biliary complications were seen in 17.6 and 21.5 percent of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6 percent of cases respectively). The overall 1 and 5 years survival rates were 80 percent and 73 percent respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91 percent. Conclusions: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries

Monitoreo de la volemia y el agua pulmonar extravascular en UCI / Monitoring of blood volume and the extravascular lung water in intensive care units

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

Carcinoides del tracto gastrointestinal: estudio anátomo-clínico / Gastrointestinal tract carcinoids: anatomo-clinical study

En el archivo de Anatomía Patológica de nuestro hospital se registraron 43 carcinoides (C) entre 1968-1988. Localización: 38 en el tracto gastrointestinal -TG- (88%) y 5 en el árbol bronquial (12%). En los C del TGI, 32 correspondieron a biopsia y 6 a necropsias, con predominio femenino (2:1) y edad X de 52 años; distribuyéndose con mayor frecuencia en apéndice (34%), íleon (32%), estómago (8%) y duodeno (8%). El 45% fue asintomático y el 55% sintomático (obstrucción, hemorragia digestiva, masa palpable y compromiso del estado general). El síndrome del carcinoide se observó en 4 casos (10%). El 45% de los tumores, especialmente los de íleon, estaban diseminados al momento del diagnóstico. Los C del TGI deben enfrentarse como cáncer, tanto en la exploración quirúrgica, como en la amplitud de la resección

Insulina intravenosa en la inercia uterina pos-parto / Intravenous insulin in post partum uterine inertia

Se presenta un caso de inercia uterina pos-parto en que el uso de insulina demostró tener un efecto retractor, después del fracaso de la Oxitocina. En esta forma fue evitada la histerectomía en una primípara. La terapia insulínica podría convertirse en alternativa de elección en esta patología antes de la solución quirúrgica