Correlación entre los Índices PaO2/FiO2 y SpO2/FiO2 en pacientes con Síndrome de Distrés Respiratorio en Ventilación Mecánica Asistida / Correlation between the PaO2 / FiO2 and SpO2 / FiO2 indices in patients with Respiratory Distress Syndrome in Mechanical Assisted Ventilation

OBJETIVO: determinar si existe correlación entre las variables índices PaO2/FiO2 y SpO2/FiO2 de pacientes con Síndrome de Distres Respiratorio Agudo -SDRA- en la Unidad de Terapia Intensiva de Adultos del Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social. MÉTODOS: estudio observacional, prospectivo, longitudinal y analítico durante el periodo de enero del 2011 a septiembre del 2013, donde se incluyeron a 52 pacientes con criterios clínicos y gasométricos de SDRA. Las variables primarias fueron PaO2, SpO2, FiO2, las cuales determinan los índices PaO2/FiO2 y SpO2/FiO2. Las variables cuantitativas se presentan pro medio de una medida de tendencia central (media) y una medida de dispersión (desviación estándar). Se utilizó un nivel de confiabilidad del 95%, para prueba de hipótesis de una proporción. El análisis de correlación para medir la fuerza de la relación entre los índices PaO2/FiO2 y SpO2/FiO2 a través del coeficiente de Correlación de Pearson. RESULTADOS: se observa buena correlación, siendo esta positiva. De acuerdo a las observaciones realizadas, se observa una correlación lineal positiva (r = 0.98, p<0.01). CONCLUSIONES: el Índice SpO2/FiO2 puede utilizarse alternativamente al índice PaO2/FiO2 en el monitoreo no invasivo respiratorio de los pacientes con SDRA...(AU)

OBJETIVE: Primary endpoint was to determine if it does exists a correlation between the PaO2/ FiO2 ratio and SpO2/FiO2 ratio in patients with Acute Respiratory Distress Syndrome (ARDS), who were admitted to the Intensive Care Unit at Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social. METHODS: We conducted a single-center, observational, prospective, longitudinal and analytical study from January 2011 to September 2013, this study included 52 critically ill patients, all of them met clinical and arterial blood gas criteria for ARDS. We review primary variables like PaO2, SpO2, FiO2, to stablish the paO2/FiO2 and SpO2/FiO2 ratio. Continuos variables were reported as means with standard deviations. The hazard ratio and its 95% confidence intervals were estimated. Pearson correlation coeficiente was use to measure of the strenght between the PaO2/FiO2 y SpO2/FiO2 ratio. RESULTS There is a good correlation, being this positive. According to the observations, we find a positive lineal correlation. (r = 0.98, p<0.01). CONCLUSIONS SPO2/FIO2 ratio can be use as an alternative of paO2/FiO2 ratio for non invasive monitoring in patients with Acute Respiratory Distress Syndrome...(AU)

Pneumonia intersticial aguda (síndrome de Hamman-Rich): relato de caso e revisão de literatura / Acute intersticial pneumonia (Hamman-Rich syndrome): a case report and literature review

A Pneumonia Intersticial Aguda (PIA) é uma rara e fulminante forma de doença pulmonar difusa descrita por Hamman e Rich em 1935. Pneumonia Intersticial Aguda é classificada como Pneumonia Intersticial Idiopática, e é a mais aguda e agressiva em seu curso. Apresenta-se clinicamente de forma similar a Síndrome da Angústia Respiratória Aguda (SARA), e representa provavelmente uma parte dos casos de síndrome da Angústia Respiratória Aguda idiopática. O caso relatado é de uma paciente de 55 anos, portadora de Obesidade e Esquizofrenia, que apresentou Insuficiência Respiratória Aguda e síndrome da Angústia Respiratória Aguda grave, com piora clínica rápida e evolução para óbito com menos de 3 dias de internação hospitalar. O diagnóstico de Pneumonia Intersticial Aguda foi feito na necropsia. O objetivo deste trabalho é fazer uma breve revisão sobre a Pneumonia Intersticial Aguda e relatar um caso clínico desta doença, que é rara e com pouca descrição na literatura, devendo ser lembrada como diagnóstico diferencial nos casos de Síndrome da Angústia Respiratória Aguda

Acute Interstitial Pneumonia (AIP) is a rare and fulminant diffuse lung disease described by Hamman and Rich in 1935. Acute Interstitial Pneumonia is classified as idiopathic interstitial pneumonia, and is the most aggressive and acute in its course. It is presented as Adult Respiratory Distress Syndrome (ARDS), and it is one of the cases of idiopathic as Adult Respiratory Distress Syndrome. This is a case of a 55 years-old patient, with obesity and schizophrenia who presented with acute respiratory insufficiency and severe as Adult Respiratory Distress Syndrome, with rapid clinical deterioration and progression to death in less than three days of hospitalization. The diagnosis of Acute Interstitial Pneumonia was made at necropsy. The objective of this paper is to briefly review the Acute Interstitial Pneumonia and to report a case of this disease, which is rare with limited description in the literature. It should be included as a differential diagnosis in cases of Adult Respiratory Distress Syndrome

Trali, una amenaza enmascarada: definición, aspectos epidemiológicos y clínicos / Trali, a masked threat: definition, epidemiological and clinical aspects

El daño pulmonar agudo relacionado con la transfusión o TRALI, como más comúnmente se le conoce, por definición no se diferencia de otros tipos de distrés respiratorios, salvo por su origen demostrable y su estrecha relación temporal con la transfusión. Constituye una de las reacciones adversas más peligrosas del uso de productos sanguíneos y sus peculiares características le permiten enmascararse entre los muchos factores que pueden desencadenar un daño pulmonar agudo, especialmente en algunos pacientes que resultan más susceptibles a su desarrollo. El propósito de esta revisión es hacer un recordatorio de su existencia, sobre todo a aquellos médicos que manejan cotidianamente pacientes demandantes de componentes sanguíneos y cuya condición clínica favorece su aparición. Sus principales variables epidemiológicas (ej: incidencia y mortalidad) varían, a veces de manera notable, entre los distintos informes. La heterogeneidad de criterios aun después de la consecución de consensos internacionales para su diagnóstico, dificulta aprovechar al máximo los datos obtenidos de los distintos estudios realizados sobre su comportamiento y ha promovido la aparición de no pocos resultados contradictorios. Su diagnóstico clínico representa un reto al presentarse en medio de contextos clínicos que hacen plantear otras causas para la aparición del distrés respiratorio. Por ello, muchas veces pasa inadvertido o es mal identificado(AU)

Transfusion-related acute lung injury better known as TRALI, has not differences with other kinds of acute respiratory distress, except for its close relation with transfusion. It is considered among the greatest hazards on blood products use. With its peculiar characteristics it mimics within the many factors that may trigger an acute respiratory distress, especially among those patients at high risk for suffering lung damage after transfusion. The main purpose of this review is to make a recall of the existence of TRALI for those physicians who deal with high transfusion-demanding patients or those with conditions which could represent a risk for its development. TRALI´s main epidemiological variables (such as incidence and mortality) show important variations among different investigations. The criteria heterogeneity, even after the consecution of international diagnostic consensus, has made it difficult to take advantage of the data arose from multiple studies about its behavior, promoting the report of not a few contradictory results on worldwide publications. Diagnosing TRALI represents a real challenge for the clinician since it often appears within the context of various possible causes for an acute respiratory distress. This is why TRALI is frequently overlooked or misdiagnosed(AU)

Pulmonary hypertension due to acute respiratory distress syndrome

Our aims were to describe the prevalence of pulmonary hypertension in patients with acute respiratory distress syndrome (ARDS), to characterize their hemodynamic cardiopulmonary profiles, and to correlate these parameters with outcome. All consecutive patients over 16 years of age who were in the intensive care unit with a diagnosis of ARDS and an in situ pulmonary artery catheter for hemodynamic monitoring were studied. Pulmonary hypertension was diagnosed when the mean pulmonary artery pressure was >25 mmHg at rest with a pulmonary artery occlusion pressure or left atrial pressure <15 mmHg. During the study period, 30 of 402 critically ill patients (7.46%) who were admitted to the ICU fulfilled the criteria for ARDS. Of the 30 patients with ARDS, 14 met the criteria for pulmonary hypertension, a prevalence of 46.6% (95% CI; 28-66%). The most common cause of ARDS was pneumonia (56.3%). The overall mortality was 36.6% and was similar in patients with and without pulmonary hypertension. Differences in patients' hemodynamic profiles were influenced by the presence of pulmonary hypertension. The levels of positive end-expiratory pressure and peak pressure were higher in patients with pulmonary hypertension, and the PaCO2 was higher in those who died. The level of airway pressure seemed to influence the onset of pulmonary hypertension. Survival was determined by the severity of organ failure at admission to the intensive care unit.

Intratracheal Administration of Umbilical Cord Blood-Derived Mesenchymal Stem Cells in a Patient with Acute Respiratory Distress Syndrome

Umbilical cord blood (UCB)-derived mesenchymal stem cells (MSCs) have been introduced as a possible therapy in acute lung injury and acute respiratory distress syndrome (ARDS). This case history is reported of a 59-yr-old man who was treated with MSCs in the course of ARDS and subsequent pulmonary fibrosis. He received a long period of mechanical ventilation and weaning proved difficult. On hospital day 114, he underwent the intratracheal administration of UCB-derived MSCs at a dose of 1 x 10(6)/kg. After cell infusion, an immediate improvement was shown in his mental status, his lung compliance (from 22.7 mL/cmH2O to 27.9 mL/cmH2O), PaO2/FiO2 ratio (from 191 mmHg to 334 mmHg) and his chest radiography over the course of three days. Even though he finally died of repeated pulmonary infection, our current findings suggest the possibility of using MSCs therapy in an ARDS patient. It is the first clinical case of UCB-derived MSCs therapy ever reported.

A Case of Vivax Malaria Complicated by Adult Respiratory Distress Syndrome and Successful Management with Extracorporeal Membrane Oxygenation

Complicated malaria is mainly caused by Plasmodium falciparum, but, increasingly, Plasmodium vivax is also being reported as a cause. Since the reemergence of indigenous vivax malaria in 1993, cases of severe malaria have been steadily reported in Korea. Herein, we report a case of vivax malaria complicated by adult respiratory distress syndrome (ARDS) that was successfully managed with extracorporeal membrane oxygenation (ECMO). A 59-year-old man presented at our hospital with fever and abdominal pain, which had persisted for 10 days. On admission, the patient had impaired consciousness, shock, hypoxia and haziness in both lungs, jaundice, thrombocytopenia and disseminated intravascular coagulation, metabolic acidosis, and acute kidney injury. A peripheral blood smear and a rapid diagnostic test verified P. vivax mono-infection. Ten hours after admission, hypoxia became more severe, despite providing maximal ventilatory support. The administration of antimalarial agents, ECMO, and continuous venovenous hemofiltration resulted in an improvement of his vital signs and laboratory findings. He was discharged from the hospital 7 weeks later, without any sequelae.

Pronóstico de pacientes ingresados a Unidad de Cuidados Intensivos por falla respiratoria asociada a presencia de infiltrados pulmonares / Prognosis of patients with acute respiratory failure and pulmonary infiltrates admitted to intensive care unit

En la unidad de cuidados intensivos (UCI), la insuficiencia respiratoria aguda (IRA) asociada a infiltrados pulmonares de causa desconocida se relaciona con alta morbilidad y mortalidad. El objetivo principal de este trabajo fue conocer el pronóstico de pacientes con IRA, infiltrados pulmonares y necesidad de ventilación mecánica (VM) ingresados a UCI. Como objetivo secundario se planteó evaluar la utilidad de medios diagnósticos de uso habitual en este grupo de pacientes en relación al pronóstico y la conducta terapéutica. Se realizó un estudio observacional retrospectivo que incluyó todos los pacientes ingresados a la UCI del Hospital Naval Almirante Nef por IRA de causa desconocida asociada a infiltrados pulmonares en radiografía de tórax y que tengan necesidad de VM entre los años 2006 y 2010. Se incluyeron 90 pacientes de los cuales 45,6 por ciento fueron de sexo masculino. La edad promedio fue 66 años (DS 17,1). El puntaje promedio de score APACHE II fue 20,6 (DS 7,7). La mortalidad fue 52,2 por ciento y el tiempo promedio de estadía en UCI fueron 14 días (DS 14,4). La principal causa de IRA fue síndrome de distress respiratorio agudo (32 por ciento).Otras causas fueron neumonía adquirida en la comunidad (28,2 por ciento), neumonía aspirativa (12,2 por ciento), neumonía nosocomial (7,8 por ciento) y neumonía criptogénica organizada (6,7 por ciento). La realización de tomografía computarizada de tórax, lavado broncoalveolar y biopsia pulmonar determinó cambio de conducta terapéutica en 31 por ciento, 58 por ciento y 88 por ciento de los casos, respectivamente. En conclusión, los pacientes con IRA tienen alta mortalidad. La causa más frecuente fue el síndrome de distress respiratorio agudo. El uso de procedimientos diagnósticos pueden cambiar las medidas terapéuticas empleadas, en especial la biopsia pulmonar.

In the intensive care unit (ICU), acute respiratory failure (ARF) associated with unexplained pulmonary infiltrates is associated with high morbidity and mortality. The main objective of this study was to determine the prognosis of patients with ARF and pulmonary infiltrates admitted to ICU. The secondary objective was proposed to evaluate the usefulness of diagnostic methods frequently used in this patient group and correlated them with prognosis and therapeutic management. We performed a retrospective observational study that included all patients admitted to ICU of Almirante Nef Naval Hospital with ARF of unknown cause associated with pulmonary infiltrates on chest radiography during the years 2006-2010. We included 90 patients of which 45 percent were male. The average age was 66 years. The average APACHE II score was 20.6. Mortality was 52.2 percent and the average length of stay in the ICU was 14 days (SD 14.4). The main cause of ARF was acute respiratory distress syndrome (32 percent). Other causes were community-acquired pneumonia (28.2 percent), aspiration pneumonia (12.2 percent), nosocomial pneumonia (7.8 percent) and cryptogenic organized pneumonia (6.7 percent. The performance of chest computed tomography, bronchoalveolar lavage and lung biopsy determined therapeutic behavior change in 31 percent 58 percent and 88 percent of cases, respectively. In conclusion, patients with ARF have high mortality. The most common cause was acute respiratory distress syndrome. The use of diagnostic procedures may change the therapeutic measures used, particularly lung biopsy.

Estresse oxidativo como evento determinante na síndrome do desconforto respiratório agudo / Oxidative stress as determinant event acute respiratory distress syndrome

A lesão pulmonar aguda e sua forma mais grave, a síndrome do desconforto respiratório agudo (SDRA), são complicações frequentes em pacientes internados em unidades de terapia intensiva, sendo responsáveis pela alta mortalidade e morbidade. Embora seja considerada uma doença multifatorial, a presença do estresse oxidativo é denominador comum e determinante no mecanismo de lesão. A maioria dos estudos experimentais confirma a importância do estresse oxidativo na patogênese da SDRA. Novas estragégias terapêuticas vêm sendo tentadas, com base nos estudos clínicos e experimentais sobre patogênese da síndrome. O artigo destaca o papel do estresse oxidativo na patogênese da síndrome, por meio de apresentação dos mais recentes estudos na área. O texto objetiva também a desmistificação do tema estresse oxidativo apresentando definições e conceitos básicos.

Acute lung injury (ALI) and its most severe form, the acute respiratory distress syhdrome (ARDS), are frequent complications in critically ill patients and are responsible for significant morbidity and mortality. Although ALI and ARDS appears to be multilfactorial, a common denominator to most of the proposed mechanisms is the cellular damage mediated by oxidative stress. Evidence of oxidative stress and injury are common to most experimental models of lung injury and are corroborated in studies of patients with ALI/ARDS, underscoring the physiologic importance of these processes. New therapies strategies have been proposed based on clinical and experimental research results. The article approaches the role of oxidative stress on ALI/ARDS and also presents the main concepts of free radicals and antioxidants.

Pseudocyst in pulmonary acute respiratory distress syndrome (ARDS).

Childhood ARDS is mostly caused by pneumonia. Pulmonary pseudocysts are reported in adults recovering from ARDS, usually in non-dependent lung regions. The authors present a 1.5-year-old boy, who survived severe pulmonary ARDS with development of pulmonary giant pseudocysts and other structural abnormalities in dependent lung region. To the best of authors knowledge, it is the first follow up report of pulmonary abnormality in a toddler with ARDS of extreme severity.

Intoxicación por Paraquat: descripción de un caso clínico / Paraquat poisoning: a case report

El paraquat es el herbicida más vendido en todo el mundo. Se absorbe por las vías digestiva e inhalatoria. Si llega a los pulmones, produce congestión, edema alveolar con aumento de macrófagos que progresa a fibrosis y edema pulmonar, los cuales se presentan hasta 14 días después de la exposición si el afectado no recibió tratamiento oportuno y correcto. El paraquat se dirige fundamentalmente a los pulmones y genera allí radicales libres oxidantes; por eso, en los casos de intoxicación aguda está totalmente contraindicado usar oxígeno excepto cuando la presión parcial de oxigeno en sangre arterial sea inferior a 50 mmHg. Se presenta un caso clínico de un paciente quien desarrolló un síndrome de distress respiratorio del adulto (SDRA) secundario a ingesta intencional de paraquat. El manejo inicial se realizó con lavado gástrico y tierra de Fuller en solución acuosa al 30%. Posteriormente, el paciente desarrolló compromiso pulmonar y renal, los cuales fueron manejados con pulso de ciclofosfamida a 15 mg/kg/día por 2 días, metilprednisolona 1g/día por 3 días y posteriormente dexametasona 5 mg IV cada 6 horas por 5 días con una evolución clínica satisfactoria.

Paraquat is the best-selling herbicide throughout the world. It is absorbed by the digestive and inhalatory routes. If it reaches the lungs, congestion with swelling is developed, increased alveolar macrophages that progresses to fibrosis and pulmonary edema, which occur until 14 days after exposure if not treated timely and correct. Paraquat is directed primarily to the lungs and therefore generates free radicals oxidants, which is why, in cases of acute poisoning is absolutely forbidden to use oxygen except where arterial blood partial pressure of oxygen in is less than 50 mm Hg. A patient who developed an adult respiratory distress syndrome (ARDS) secondary to deliberate ingestion of paraquat is presented. Initial patient management was performed with gastric lavage and land Fuller in aqueous solution at 30%. Subsequently developing pulmonary and renal failure were handled with cyclophosphamide pulse of 15 mg/kg/day for 2 days, methylprednisolone 1g/día for 3 days, then dexamethasone 5 mg IV every 6 hours for 5 days, with favourable outcome.

Acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a syndrome of injured lung due to any systemic inflammatory responses. The decline in ARDS mortality mostly attributed to improvements in standard supportive care. There are still no data from any large multicenter randomized clinical trial ever demonstrated to reduce mortality other than the recommended by the National Institutes of Health (NIH) ARDS Network published in 2000.

Ventilación de alta frecuencia oscilatoria en el rescate de hipoxemia catastrófica en niños con síndrome de distrés respiratorio agudo / High frequency oscillatory ventilation on catastrophic hypoxemia childs with acute respiratory distress syndrome

Introducción: La ventilación de alta frecuencia oscilatoria (VAFO) es una modalidad empleada en pacientes con Síndrome de Distress Respiratorio Agudo (SDRA) refractario a ventilación mecánica convencional (VMC). El rol de esta terapia frente a hipoxemia catastrófica, con índice de oxigenación (IO >= 40), no está definido en la actualidad, por corresponder a pacientes habitualmente subsidiarios de soporte extracorpóreo. Objetivo: Presentar el efecto de la VAFO en SDRA grave con hipoxemia extrema, refractaria a terapia convencional máxima. Diseño y pacientes: Se empleó el ventilador Sensor Medics 3100A según protocolo preestablecido. Describimos la totalidad de los pacientes con insuficiencia respiratoria que ingresaron entre 1999 y 2005 en nuestra unidad que tras terapia ventilatoria convencional permanecieron con índice de oxigenación mayor que 40. Se registró intercambio gaseoso antes, durante las primeras 48 h y previo al retorno a VMC. Describimos permanencia en VAFO, complicaciones y mortalidad en este grupo. Mediciones y resultados: Se ventilaron 12 pacientes con una mediana de edad de 3,5 meses; score de lesión pulmonar de 3,5 (3,25-4). Previo al inicio de la VAFO, la PaO2/FIO2 y el IO fueron de 39 y 47 respectivamente. La duración de la VMC previa fue de 65 h. Esta terapia logró una rápida y progresiva mejoría de la oxigenación, máxima a las 24 h de iniciada (PaO2/FIO2=137 e IO=18, p<0,01). La supervivencia a los 28 días fue de 75 por ciento. Conclusión: Una elevada supervivencia asociado a la mejoría en la oxigenación puede ser obtenida en pacientes con hipoxemia extrema empleando la VAFO, por lo que se constituye en opción terapéutica a considerar en este subgrupo.

Introduction: High frequency oscillatory ventilation (HFOV) is a ventilatory modality which has demonstrated to be useful in patients with Acute Respiratory Distress Syndrome (ARDS) refractory to conventional mechanical ventilation (CMV). The role of this therapy on catastrophic hypoxemia (oxygenation index [OI] over 40) is not clearly defined yet since these patients are suitable for extracorporeal support therapy nowadays. Objective: To report the effect of HFOV in severe ARDS refractory to maximal CMV therapy. Design and patients: A Sensor Medics 3100A ventilator was used. We considered all the patients who were admitted between 1999 and 2005 for acute respiratory failure who remained with OI over 40 despite maximal CMV. The record included arterial blood gases immediately before and during the first 48 hours of HFOV, and prior to the switch onto CMV. We analyzed the duration on HFOV, the presence of complications and the mortality rate of the group. Measurements and results: Twelve patients were enrolled with a median age of 3.5 months, and lung injury score of 3.5 (range: 3.25 to 4). Prior to HFOV the median PaO2/FIO2 ratio and OI were 39 and 47, respectively. The previous CMV duration was 65 hours. The therapy was extremely useful in improving the oxygenation obtaining the maximal effect at the 24 hours of therapy (PaO2/FIO2 ratio= 137 e IO=18, p<0.01). The survival rate was 75 percent on day 28. Conclusions: A reasonably high survival rate associated with an improvement of the oxygenation is achieved in patients with extreme hypoxemia using HFOV. Thus, this therapy should be considered in this group.

Cierre efectivo por vía broncoscópica de fístula broncopleural de alto flujo en paciente con síndrome de distress respiratorio agudo grave / High flow bronchopleural fistula effective bronchoscopic closure in a patient with acute respiratory distress syndrome

Introducción: La fístula broncopleural (FBP) secundaria a cirugía o infección es un reto terapéutico. Su tratamiento puede ser expectante o quirúrgico, describiéndose cada vez más el cierre endoscópico. Objetivo: Descripción de caso clínico de un paciente en quién se logró el cierre de una FBP vía endoscópica mientras evolucionaba con un síndrome de distress respiratorio agudo (SDRA) grave. Caso clínico: Paciente de 14 años de edad con antecedente de lobectomía inferior izquierda por bronquiectasias crónicas, quien desarrolló una FBP central secundaria al drenaje transtorácico de un absceso lingular. Presentó un shock séptico asociado a un SDRA. En su evolución la FBP de alto flujo impidió una ventilación mecánica adecuada, siendo esta cerrada por vía broncoscópica con tetraciclina y Gelfoam®, lo que permitió una disminución significativa de su débito, con cierre definitivo a las tres semanas del procedimiento. Conclusión: La FBP secundaria a un absceso pulmonar, puede ser tratada eficientemente con selle fibrobroncoscópico durante el curso de un fallo respiratorio grave en un paciente críticamente enfermo, evitando alternativas quirúrgicas de mayor riesgo.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estaban ya archivados (2a parte): La paciente obstétrica. Una actualización / Lessons learned from the ASA Closed Claims Project (ASACCP). ASA Project about the reasons for wich claims against anesthesiologists were rewed in cases that had already been close (part 2): The obstetric patient. An update

El análisis de los últimos casos relacionados con el tema fue publicado en el año 1996 cuando en la base de la ASACCP constaban 3533 demandas terminadas. De éstas, 434 estuvieron relacionadas con la anestesia obstétrica. De las 434 demandas relacionadas con la anestesia obstétrica, 310 correspondieron a la operación cesárea y 124 al parto por vía vaginal con anestesia regional. Las muertes maternas (n=83) y el daño cerebral del recién nacido (n=82) continúan siendo las injurias más frecuentes en las pacientes obtétricas. La muerte materna estuvo más comúnmente relacionada con la anestesia general y con la operación cesárea. A pesar de que el número de muertes maternas consecutivas a la anestesia general se mantuvo estable a través de los años, el número de muertes asociadas a la anestesia regional declinó en forma marcada. Este decremento de muertes maternas bajo anestesia regional ocurrió sobre todo en los años 80, coincidiendo con la prohibición del uso de bupivacaína al 0,75 por ciento. Además, esta declinación se debe, sin duda, a la solución de los problemas creados por la vía aérea, la cual es más difícil de acceder en la mujer embarazada (1:270 en la paciente obstétrica, contra 1:2.230 de la no obstétrica). La necesidad de controlar la vía aérea es crucial para reducir los casos de muerte durante anestesia general. Lo mismo sucede con la anestesia regional cuando la altura del bloqueo es muy elevada o por cualquier otra razón que obligue a convertir una anestesia regional en una general. Siempre existe el temido problema de la aspiración de contenido gástrico, que sigue siendo la primera causa de muerte materna durante la anestesia y casi siempre asociada con una intubación dificultosa o fallida. El daño cerebral del recién nacido se produjo en el 19 por ciento de las demandas estudiadas por la ASACCP. En una Unidad de Cuidados Intensivo de recién nacidos en EE.UU se realizó un estudio retrospectivo, como los estudios de la ASACCP, para analizar el número de demandas relacionadas con los casos internados en dicha unidad. El estudio comprendió el período 1972-1992 durante el cual se produjeron 31 demandas por mala praxis sobre 9367 internaciones, con una incidencia de 0,33 por ciento. Según los autores, la frecuencia de juicios contra los anestesiólogos por problemas vinculados con el recién nacido se incrementó del 0,19 por ciento entre los años 1772-1974 al 0,39 entre 1980 y 1992...

Neuroleptic-induced acute respiratory distress syndrome

CONTEXT: A case of neuroleptic malignant syndrome and acute respiratory distress syndrome is presented and discussed with emphasis on the role of muscle relaxation, creatine kinase, and respiratory function tests. CASE REPORT: A 41-year-old man presented right otalgia and peripheral facial paralysis. A computed tomography scan of the skull showed a hyperdense area, 2 cm in diameter, in the pathway of the anterior intercommunicating cerebral artery. Preoperative examination revealed: pH 7.4, PaCO2 40 torr, PaO2 80 torr (room air), Hb 13.8 g/dl, blood urea nitrogen 3.2 mmol/l, and creatinine 90 mmol/l. The chest x-ray was normal. The patient had not eaten during the 12-hour period prior to anesthesia induction. Intravenous halothane, fentanyl 0.5 mg and droperidol 25 mg were used for anesthesia. After the first six hours, the PaO2 was 65 torr (normal PaCO2) with FiO2 50 percent (PaO2/FiO2 130), and remained at this level until the end of the operation 4 hours later, maintaining PaCO2 at 35 torr. A thrombosed aneurysm was detected and resected, and the ends of the artery were closed with clips. No vasospasm was present. This case illustrates that neuroleptic drugs can cause neuroleptic malignant syndrome associated with acute respiratory distress syndrome. Neuroleptic malignant syndrome is a disease that is difficult to diagnose. Acute respiratory distress syndrome is another manifestation of neuroleptic malignant syndrome that has not been recognized in previous reports: it may be produced by neuroleptic drugs independent of the manifestation of neuroleptic malignant syndrome. Some considerations regarding the cause and effect relationship between acute respiratory distress syndrome and neuroleptic drugs are discussed. Intensive care unit physicians should consider the possibility that patients receiving neuroleptic drugs could develop respiratory failure in the absence of other factors that might explain the syndrome

Presentación de 1 caso con neumonía varicelosa y distrés respiratorio / Presentation of a case with varicella pneumonia and respiratory distress

Se presentó un caso de 46 años, masculino, con antecedentes de salud, que mantuvo contacto con niños portadores de varicela y que llegó a nosotros con lesiones en la piel típicas de varicela, falla respiratoria aguda y alteraciones de la coagulación. Se trató con aciclovir, intacglobin, y ventilación mecánica, a pesar de lo cual falleció antes de las 24 h de su ingreso, aunque debemos destacar que el tratamiento comenzó tardíamente y no existían antecedentes de vacunación previa. Se decidió presentar este caso, por la poca frecuencia de la varicela complicada en adultos sanos