Complicaciones tromboembólicas y hemorrágicas en pacientes portadores de prótesis valvulares del corazón en un centro de tercer nivel. ¿Qué hemos aprendido? / Thromboembolic and hemorrhagic complications in patients with prosthetic heart valves at third level care center. What have we learned?

Resumen Antecedentes: El reemplazo valvular por prótesis mecánicas o biológicas implica riesgo de tromboembolismo y complicaciones hemorrágicas. Objetivo: Determinar las complicaciones relacionadas con la terapia de anticoagulación complementaria y la probabilidad de riesgo en pacientes portadores de prótesis valvulares del corazón. Métodos: Se estudiaron 163 pacientes entre 2002 y 2016, portadores de prótesis mecánicas y biológicas, quienes recibieron antagonistas de la vitamina K posterior al egreso hospitalario. La terapia de anticoagulación se categorizó en óptima y no óptima conforme a los valores de INR previos a las complicaciones. Fueron excluidos los pacientes con comorbilidades y otros factores de riesgo de trombosis y/o sangrado. Resultados: a 68.7 % de los pacientes se les colocó prótesis mecánica y a 31.3 %, biológica (p ≤ 0.001); 25.2 % presentó las complicaciones motivo de estudio (p ≤ 0.001), hemorrágicas en 48.8 %, tromboembólicas en 26.8 % y de ambos tipos en 24.4 % (riesgo relativo = 4.229); a 95.1 % de los pacientes con complicaciones se les colocó prótesis mecánica y a 4.9 %, biológica (p = 0.005); 49.7 % presentó INR no óptimo (p ≤ 0.001). Conclusiones: Ante riesgo alto de complicaciones tromboembólicas y hemorrágicas, la elección de las prótesis valvulares, la prevención y el seguimiento son prioridades, principalmente en quienes requieren terapia de anticoagulación.

Abstract Background: Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications. Objective: To determine the complications related to complementary anticoagulation therapy and the probability of risk. Methods: One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded. Results: In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001). Conclusions: Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.

Índice de sarcopenia en pacientes hospitalizados por agudización de la enfermedad pulmonar obstructiva crónica / Sarcopenia index in hospitalized patients with chronic obstructive pulmonary disease exacerbation

Resumen La presencia de sarcopenia (pérdida de masa y función muscular) implica peor pronóstico. Sin embargo, su diagnóstico es complejo y no se realiza en la atención clínica habitual. Se ha propuesto un biomarcador como estimador subrogado de la masa muscular esquelética, el denominado índice de sarcopenia ([creatinina sérica/cistatina C] x100) que se asocia a características pronósticas en diversas enfermedades incluyendo pacientes con enfermedad pulmonar obstructiva crónica (EPOC) estable. El objetivo de nuestro estudio ha sido evaluar de forma prospectiva la potencial información clínica y pronóstica de este biomarcador en agudización de la EPOC. Se trata de un estudio prospectivo, durante un año, de los pacientes consecutivos que ingresan por agudización de su EPOC. Se incluyeron 89 pacientes, 70 varones (79%) y 19 mujeres (21%). Aquellos con valores disminuidos del índice de sarcopenia tenían más disnea y requerían una internación más prolongada. En el análisis de correlación se obtuvo valores con significación estadística del índice con FEV1 (r = 0.23), PaCO (r = -0.30) y bicarbonato (r = -0.31), y con la disnea (r = -0.25) y la duración del ingreso (r =0.30). En los ingresados por agudización de la EPOC el índice de sarcopenia se relacionó con características pronósticas, de modo que los valores inferiores se asociaron a mayor duración de la internación, más disnea y mayor afectación funcional. Al tratarse de un índice asociado a la masa muscular, su determinación podría identificar a pacientes a incluir en un plan terapéutico diferenciado.

Abstract Sarcopenia (loss of muscle mass and function) implies a worse prognosis. However, its diagnosis is complex and is not made in routine clinical care. A biomarker has been proposed as a surrogate estimator of skeletal muscle mass, the so-called sarcopenia index ([serum creatinine/cystatine C] x100) which is associated with prognostic features in various diseases including patients with stable chronic obstructive pulmonary disease (COPD). The aim of our study was to prospectively evaluate the potential clinical and prognostic information of this biomarker in COPD exacerbation. This is a one-year prospective study of consecutive patients admitted for COPD exacerbation. A total of 89 patients, 70 men (79%) and 19 women (21%) were included. Those with lower values of the sarcopenia index had a higher level of dyspnoea and a longer hospitalization. In the correlation analysis, the index had statistically significant values with FEV1 (r = 0.23), PaCO (r = -0.30), bicarbonate (r = -0.31), dyspnoea (r = -0.25) and length of admission (r = -0.30). In patients admitted for COPD exacerbation, the sarcopenia index was related to prognostic characteristics, so that lower values were associated with longer duration of hospital admission, more dyspnoea and greater functional impairment. As this is an index associated with muscle mass, its determination may identify patients who could be the subject of a differentiated therapeutic plan.

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.

Hiperlactatemia en pacientes hospitalizados por asma: Frecuencia e implicaciones clínicas / Hyperlactatemia in hospitalized patients with asthma. Frequency and clinical implications

Se ha descrito un incremento del lactato sanguíneo en algunos pacientes tratados por agudización del asma. Sin embargo, se desconoce su frecuencia y el significado clínico en la práctica clínica habitual. El objetivo del estudio ha sido evaluar las características asociadas a la presencia de hiperlactatemia en la gasometría arterial de pacientes que requirieron ingreso en la sala de neumonología por agudización del asma. Se realizó un estudio retrospectivo de las altas hospitalarias de un servicio de neumonología durante 3 años (2015 a 2017) analizando los valores del ácido láctico en la gasometría arterial y su posible relación con datos de antecedentes clínicos, de laboratorio, tratamiento, espirometría, estancia hospitalaria o uso de unidades de cuidados críticos. Se incluyeron 112 pacientes con 182 ingresos. Presentaron en alguna ocasión hiperlactatemia (> 2.2 mmol/l) 32 pacientes (29%). En 42 de los 182 ingresos (23%) se observó aumento de lactato, en quienes tenían mayor estancia hospitalaria (mediana 6 vs. 5 días, p = 0.013). En 8 de los 10 ingresos en unidades de cuidados críticos se observó hiperlactatemia, en general tras recibir el tratamiento broncodilatador. En las gasometrías con hiperlactatemia existía una correlación significativa entre lactato y bicarbonato (r = -0.417, p=0.003) y el exceso de base (r = -0.484, p < 0.001). La hiperlactatemia es relativamente frecuente en las gasometrías realizadas a los pacientes hospitalizados por asma (23% de los ingresos). Los ingresos con hiperlactatemia se asociaron a una internación más prolongada.

Increased levels of lactic acid have been described in patients treated for asthma exacerbation. However, the frequency and clinical significance of hyperlactatemia in real-world practice is unknown. The objective of the study was to evaluate the characteristics associated with hyperlactatemia in blood gas analysis of patients with asthma exacerbation hospitalized in a pulmonary department. This is a retrospective 3-year study (2015 to 2017) of patients discharged from the pulmonary department. The level of lactic acid in the blood gas test and the possible relationship with clinical, laboratory, therapy, spirometric values, hospitalization length and use of critical care resources were analyzed. A total of 112 patients with 182 admissions were included in the study. Thirty-two (29%) patients had hyperlactatemia in at least one blood gas analysis. Elevated lactic acid was observed in 42 of 182 admissions (23%), which had larger length hospital stay (median, 6 vs. 5 days, p = 0.013). Hyperlactatemia was present in 8 of 10 admissions in the critical care units, mainly after receiving bronchodilator therapy. There was a significant correlation between lactate level and bicarbonate level (r = -0.417, p = 0.003) and between lactate level and base excess (r = -0.484, p < 0.001) in cases with hiperlactatemia. Hyperlactatemia is a relatively frequent finding in blood gas analysis of patients hospitalized because of asthma (23% of admissions). These admissions with hiperlactatemia are associated with larger hospital length of stay.

Propuesta de políticas públicas que relacionen el ambiente como determinante del estado de salud poblacional e individual: resumen ejecutivo de propuestas para los candidatos a la presidencia de la república y al parlamento / Public politics proposal considering environment as population and individual health determinant executive summary of proposals to the candidates to the republic presidency and parliament

El Departamento de Medio Ambiente del Colegio Médico de Chile ha concordado una serie de medidas que a su juicio deben ser implementadas por las nuevas autoridades políticas de Chile elegidas, con el fi n de corregir aquellos problemas ambientales que son determinantes de salud poblacional e individual. La implementación de estas medidas deberá impactar positivamente en la salud y calidad de vida de los habitantes de Chile, disminuir la mortalidad aguda y o diferida causada por exposición a diversos contaminantes ambientales. En especial, deberá afectar positivamente a las futuras generaciones al disminuir la exposición prenatal o infantil temprana a agentes que determinan el desarrollo de enfermedades o cambios conductuales más tarde en la vida. Estas proposiciones fueron entregadas a todos los candidatos presidenciales y explicadas en reuniones con cada uno de los 4 candidatos presidenciales que tienen las mejores opciones de de ser electos, de acuerdo a encuestas realizadas en el país.

The Environment Department of the Colegio Médico de Chile (Chilean College of Physicians) agreed a series of measures that should be implemented by the new elected Chilean political authorities, with the purpose of correction the environmental problems which are population and individual health determinants. The implementation of these measures should positively impact Chilean population health and quality of life and decrease acute or delayed mortality caused by exposure to various pollutants. Especially, it should positively affect future generations preventing prenatal or infant exposure to agents determining the development of diseases or behavioural changes later in life. These proposals were delivered to all presidential candidates, and explained in meetings with each of the four presidential candidates with the best perspectives to be elected, according to opinion polls carried out in the country.

Diagnóstico de infarto miocárdico perioperatorio dentro de las primeras 72 horas posteriores a la cirugía cardiaca / Diagnosis of perioperative myocardial infarction within the first seventy-two hours after cardiac surgery

One of the most frequent complications of cardiac surgery is the perioperative myocardial infarction (PMI). Incidence of PMI shows a wide variation because an accurate detection of this complication is difficult in the early postoperative stage. The objectives of the present study were to determine in our population of patients the incidence of PMI during the first seventy two hours after cardiac surgery as well as associations among the accepted criteria to diagnose this complication. PATIENTS AND METHODS: One hundred sixty four adults patients undergoing elective cardiac surgery were studied. With baselines preoperative studies, serial electrocardiographic, enzymatic [(determination of serum creatine kinase isoenzyme (CK-MB)] and echocardiographic studies were performed during the first 72 hours after cardiac surgery. Diagnosis of PMI was established with two or all the three positive criteria [electrocardiographic (ECG), enzymatic (CK-MB) and echocardiographic (ECHO)]. RESULTS: In 24 (15%) patients PMI was diagnosed. In this group 13 (54%) all the three criteria were positive. In 8 (33%) patients CK-MB and ECHO were positive. In 3 (13%) patients CK-MB and ECG were positive. CONCLUSIONS: In our population the incidence of PMI (15%) is agree with the reported in previous studies. In most of cases of PMI all the three diagnostic criteria are positive. When diagnosis is established only with two criteria, in most of cases these are CK-MB and ECHO.