Determinantes precoces en el desarrollo de injuria renal aguda durante la sepsis abdominal experimental / Early determinants of acute kidney injury during experimental intra-abdominal sepsis

Background: Sepsis-induced acute kidney injury (AKI) is an early and frequent organ dysfunction, associated with increased mortality. Aim: To evaluate the impact of macrohemodynamic and microcirculatory changes on renal function and histology during an experimental model of intra-abdominal sepsis. Material and Methods: In 18 anaesthetized pigs, catheters were installed to measure hemodynamic parameters in the carotid, right renal and pulmonary arteries. After baseline assessment and stabilization, animals were randomly divided to receive and intra-abdominal infusion of autologous feces or saline. Animals were observed for 18 hours thereafter. Results: In all septic animals, serum lactate levels increased, but only eight developed AKI (66%). These animals had higher creatinine and interleukin-6 levels, lower inulin and para-aminohippurate clearance (decreased glomerular filtration and renal plasma flow), and a negative lactate uptake. Septic animals with AKI had lower values of mean end arterial pressure, renal blood flow and kidney perfusion pressure, with an associated increase in kidney oxygen extraction. No tubular necrosis was observed in kidney histology. Conclusions: The reduction in renal blood flow and renal perfusion pressure were the main mechanisms associated with AKI, but were not associated with necrosis. Probably other mechanisms, such as microcirculatory vasoconstriction and inflammation also contributes to AKI development.

Controversias en tromboembolismo pulmonar masivo / Controversies in massive pulmonary embolism

Massive pulmonary embolism (PE) is associated with high mortality. There is still a broad assortment of severity classifications for patients with PE, which affects the choice of therapies to use. The main clinical criteria for defining a PE as massive is systemic arterial hypotension, which depends on the extent of vascular obstruction and the previous cardiopulmonary status. Right ventricular dysfunction is an important pathogenic element to define the severity of patients and short term clinical prognosis. The recommended treatment is systemic thrombolysis, but in centers with experience and resources, radiological invasive therapies through catheters are useful alternatives that can be used as first choice tools in certain cases.

Tromboembolismo pulmonar: estratificación de riesgo y dilemas terapéuticos / Risk stratification of pulmonary thromboembolism

Background: The prognosis of pulmonary thromboembolism (PE) is related to the cardiopulmonary reserve of the patient and the magnitude of the embolus that impacts pulmonary circulation. The presence of hemodynamic instability (shock) stratifies a group of patients with high mortality, which should be treated with thrombolysis. Patients without shock but with right ventricular dysfunction can have a dismal evolution and should be managed aggressively. CAT scan, echocardiography and serum markers can be of value to define patients with a higher mortality. The available evidence to define the best diagnostic and therapeutic strategy is scanty, controversial and inconclusive. A good combination of clinical, imaging and biological markers should be defined to identify those patients without shock but with a high rate of complications and mortality, that could benefit from aggressive treatments.

Resultados preliminares y factibilidad del mini lavado bronco-alveolar en pacientes cursando falla respiratoria severa / Mini bronchoalveolar lavage in patients with severe respiratory failure

Background: To recognize the etiological agent responsible for severe acute respiratory failure (ARF) in patients in mechanical ventilation (MV) is important to determine their treatment and prognosis, and to avoid the excessive use of antibiotics. Mini bronchoalveolar lavage (mini BAL) is a blind, non bronschoscopic procedure, used to obtain samples from the lower respiratory tract from patients on mechanical ventilation (MV). Aim: To assess the feasibility, complications and preliminary results of mini BAL among patients with severe ARF on MV. Material and Methods: Prospective study in 17 patients with acute lung injury (ALI ) or acute respiratory distess syndrome (ARDS) on MV and with negative conventional microbiological studies. Mini BAL was performed using standardized protocols. Hemodynamic and respiratory parameters where measured before and after the procedure. Samples obtained were sent to quantitative cultures. Results: At baseline: APACHE II score of 22 ± 6,7, PaO2/FiO2 ratio was 176.6 ± 48.6 and the oxygenation index was 9.74 ± 3.78. All procedures were performed by an ICU resident. Thirty five percent of the procedures had positive cultures and no complications related to the procedures were reported. The procedure lasted an average of 12 minutes and the instilled and rescued volume were 60 ml and 19.6 ml, respectively. There were no significant differences between hemodynamic and respiratory variables before and after the procedure. Conclusions: Mini BAL is a safe, fast and easy technique for obtaining samples from the inferior airway in patients with ALI or ARDS on MV.

Embolia por líquido amniótico: una puesta al día a propósito de un caso / Amniotic fluid embolism: a case report and update

Se presenta el caso clínico de una mujer de 17 años de edad, cursando un embarazo de 33 semanas, que ingresa al hospital por trabajo de parto prematuro. Se descartó infección de la unidad feto-placentaria y materna. Se manejo mediante inhibición del trabajo de parto con fenoterol e inducción de madurez pulmonar con corticoides. Evolucionó satisfactoriamente. En el puerperio inmediato, la madre presenta cuadro de insuficiencia respiratoria aguda, por lo que debe ser trasladada a Unidad de Cuidados Intensivos donde es estabilizada inicialmente con oxígeno 100 por ciento por mascarilla de recirculación, diuréticos e infusión continua de nitroglicerina. Se realizó angiografía pulmonar por tomografía axial computarizada, que evidenció la presencia de imágenes compatibles con embolia por líquido amniótico. El diagnóstico se planteó una vez excluidos sistemáticamente los diagnósticos de edema pulmonar agudo cardiogénico, tromboembolismo pulmonar, aspiración bronquial y neumonía. La paciente evolucionó satisfactoriamente, disminuyendo paulatinamente sus requerimientos de oxígeno, siendo dada de alta días más tarde, asintomática.

Utilidad del ecocardiograma y de marcadores séricos en la estratificación de riesgo en pacientes cursando con embolia pulmonar submasiva / Utility of echocardiogram and serum markers in the risk stratification in patients attending with submassive pulmonary embolism

Los pacientes que cursan tromboembolismo, dependiendo de su severidad, pueden recibir variados tratamientos no exentos de efectos adversos. Existe, por lo tanto, la necesidad de estratificar riesgo -magnitud- mortalidad con criterios que le permitan al clínico tomar las mejores decisiones. En este artículo se pretende establecer un sistema de aproximación al tromboembolismo pulmonar de acuerdo a la información hasta ahora disponible.