Aiming for zero fluid accumulation: First, do no harm.

Critically ill patients are often presumed to be in a state of "constant dehydration" or in need of fluid, thereby justifying a continuous infusion with some form of intravenous (IV) fluid, despite their clinical data suggesting otherwise. Overzealous fluid administration and subsequent fluid accumulation and overload are associated with poorer outcomes. Fluids are drugs, and their use should be tailored to meet the patient's individualized needs; fluids should never be given as routine maintenance unless indicated. Before prescribing any fluids, the physician should consider the patient's characteristics and the nature of the illness, and assess the risks and benefits of fluid therapy. Decisions regarding fluid therapy present a daily challenge in many hospital departments: emergency rooms, regular wards, operating rooms, and intensive care units. Traditional fluid prescription is full of paradigms and unnecessary routines as well as malpractice in the form of choosing the wrong solutions for maintenance or not meeting daily requirements. Prescribing maintenance fluids for patients on oral intake will lead to fluid creep and fluid overload. Fluid overload, defined as a 10% increase in cumulative fluid balance from baseline weight, is an independent predictor for morbidity and mortality, and thus hospital cost. In the last decade, increasing evidence has emerged supporting a restrictive fluid approach. In this manuscript, we aim to provide a pragmatic description of novel concepts related to the use of IV fluids in critically ill patients, with emphasis on the different indications and common clinical scenarios. We also discuss active deresuscitation, or the timely cessation of fluid administration, with the intention of achieving a zero cumulative fluid balance.

Incidence of high body mass index in critically ill cancer patients.

OBJECTIVE: The aims of this study were to describe the incidence of obesity and overweight in critically ill cancer patients, and to evaluate the clinical characteristics and Intensive Care Unit (ICU) outcomes of critically ill cancer patients with obesity and overweight. METHODS: An observational cohort study. There were no interventions. RESULTS: During the study period, 483 critically ill cancer patients were admitted to ICU, and 59.2% of them (258 patients) had high body mass index (BMI). Comparing the groups of patients with BMI < 25 kg/m2 and ≥ 25 kg/m2, we observed that those with BMI ≥ 25 kg/m2 were older at the time of admission to the ICU. The global mortality in ICU was of 22.4%. ICU mortality was similar between patients with BMI < 25 kg/m2 and ≥ 25 kg/m2 (21.3% versus 23.0%, p = 0.649). Univariate analysis indicated that the following five factors were associated with ICU death in patients with BMI ≥ 25 kg/m2 as the outcome variable of interest: age, sepsis, invasive mechanical ventilation, type 2 diabetes, ≥ two organ failures. Multivariate analysis identified ≥ two organ failures as independent prognostic factor of ICU death. CONCLUSION: Critically ill cancer patients have a high incidence of high BMI; approximately six of every ten patients admitted to the ICU with a serious condition are overweight or show several degrees of obesity. The ICU mortality of the patients with a body mass index < 25 kg/m2 and ≥ 25 kg/m2 was similar. The independent prognostic factor of ICU death in critically ill patients with a BMI ≥ 25 kg/m2 was the number of organ dysfunctions, especially when two or more organs were affected.

[Laparoscopic radical trachelectomy for preservation of fertility in early cervical cancer. A case report]. / Traquelectomía radical laparoscópica para preservación de la fertilidad en cáncer de cérvix etapa temprana. Reporte de un caso.

BACKGROUND: Radical hysterectomy is the standard treatment for patients with early-stage cervical cancer. However, for women who wish to preserve fertility, radical trachelectomy is a safe and viable option. OBJECTIVE: To present the first case of laparoscopic radical trachelectomy performed in the National Cancer Institute, and published in Mexico. CLINICAL CASE: Patient, 34 years old, gravid 1, caesarean 1, stage IB1 cervical cancer, squamous, wishing to preserve fertility. She underwent a laparoscopic radical trachelectomy and bilateral dissection of the pelvic lymph nodes. Operation time was 330minutes, and the estimated blood loss was 100ml. There were no intraoperative or postoperative complications. The final pathology reported a tumour of 15mm with infiltration of 7mm, surgical margins without injury, and pelvic nodes without tumour. After a 12 month follow-up, the patient is having regular periods, but has not yet tried to get pregnant. No evidence of recurrence. CONCLUSIONS: Laparoscopic radical trachelectomy and bilateral pelvic lymphadenectomy is a safe alternative in young patients who wish to preserve fertility with early stage cervical cancer.

[Pulmonary hypertension associated with connective tissue diseases]. / Hipertensión arterial pulmonar por ecocardiografía en pacientes con enfermedades de tejido conectivo.

BACKGROUND: Pulmonary arterial hypertension is an important cause of complications among patients with connective tissue diseases. AIM: To describe the clinical and echocardiographic characteristics of patients with pulmonary hypertension associated with connective tissue diseases. MATERIAL AND METHODS: Retrospective, observational and descriptive study. We analyzed 35 patients with pulmonary hypertension associated with connective tissue diseases. All patients were evaluated and diagnosed by at least one medical specialist in rheumatology. Pulmonary arterial hypertension was defined as a pulmonary artery systolic pressure ≥ 40 mmHg by echocardiography. The group was divided as not severe when pressures ranged from 40 to 64 mmHg and severe, when pressures were ≥ 65 mmHg. RESULTS: The most common connective tissue disease associated with pulmonary arterial hypertension was diffuse scleroderma in 46% of cases. Eighty nine percent of patients were female. Time of evolution of the pulmonary hypertension was 18.8 ± 21.8 months. The distance walked in the six minute walk test was < 400 m both in patients with and without severe pulmonary hypertension. Fifty one percent of patients had pulmonary restriction. No differences in gas exchange parameters were observed between groups. Comparing echo cardio-graphic findings in patients with and without severe hypertension, the former had a higher frequency of right ventricular dilatation (85.7 and 52.3% respectively, p = 0.04), right ventricular hypertrophy (42.8 and 0% respectively, p = 0.02) and right ventricular hypokinesia (71.4 and 9.5% respectively p = < 0.01). CONCLUSIONS: Patients with severe pulmonary arterial hypertension associated to connective tissue diseases have more commonly dilated, hypertrophic and hypokinetic right ventricles.

Hipertensión arterial pulmonar por ecocardiografía en pacientes con enfermedades de tejido conectivo / Pulmonary hypertension associated with connective tissue diseases

Background: Pulmonary arterial hypertension is an important cause ofcomplica-tions amongpatients with connective tissue diseases. Aim: To describe the clinical and echocardiographic characteristics ofpatients with pulmonary hypertension associated with connective tissue diseases. Material and Methods: Retrospective, observational and descriptive study. We analyzed 35 patients with pulmonary hypertension associated with connective tissue diseases. All patients were evaluated and diagnosed by at least one medical specialist in rheumatology. Pulmonary arterial hypertension was defined as a pulmonary artery systolic pressure ≥ 40 mmHg by echocardiography. The group was divided as not severe when pressures ranged from 40 to 64 mmHg and severe, when pressures were ≥ 65 mmHg. Results: The most common connective tissue disease associated with pulmonary arterial hypertension was diffuse scleroderma in 46% of cases. Eighty nine percent of patients were female. Time of evolution of the pulmonary hypertension was 18.8 ± 21.8 months. The distance walked in the six minute walk test was < 400 m both in patients with and without severe pulmonary hypertension. Fifty one percent ofpatients had pulmonary restriction. No differences in gas exchange parameters were observed between groups. Comparing echocardio-graphic findings in patients with and without severe hypertension, the former had a higher frequency ofright ventricular dilatation (85.7 and 52.3% respectively, p = 0.04), right ventricular hypertrophy (42.8 and 0% respectively, p = 0.02) and right ventricular hypokinesia (71.4 and 9.5% respectively p = < 0.01). Conclusions: Patients with severe pulmonary arterial hypertension associated to connective tissue diseases have more commonly dilated, hypertrophic and hypokinetic right ventricles.

[Ventilator associated acute lung injury]. / Daño pulmonar agudo asociado a ventilación mecánica.

Mechanical ventilation plays a central role in the critical care setting; but its use is closely related with some life threatening complications as nosocomial pneumonia and low cardiac performance. One of the most severe complications is called ventilator-associated lung injury (VALI) and it includes: Barotrauma, volutrauma, atelectrauma, biotrauma and oxygen-mediated toxic effects and it is related with an inflammatory response secondary to the stretching and recruitment process of alveoli within mechanical ventilation. The use of some protective ventilatory strategies has lowered the mortality rate 10% approximately.

[Myocardial depression in a patient with celiac disease. A clinical case report and literature review]. / Depresión miocárdica en un enfermo con esprue celiaco. Reporte de un caso y revisión de la literatura.

We report an autoinmune myocarditis case as a complication of celiac disease in a 28 year old woman. She had a 15 month history or diarrhea. She suffered pelvic trauma due to an episode of syncope and was admitted with refractory shock to fluid repletion. At laparotomy, two moderate hematomas were found in the subcutaneous space and retroperitoneum. Later she developed hemodynamic instability requiring positioning of a Swan-Ganz pulmonary artery catheter that demonstrated pattern of cardiogenic shock. Echocardiography demonstrated dilation of all four cavities and 35% ejection fraction. Dobutamine and milrinone infusion was begun. Later, a new echocardiographic study show improvement in eyection fraction. She was discharged without complications.

Daño pulmonar agudo asociado a ventilación mecánica / Ventilator associated acute lung injury

Mechanical ventilation plays a central role In the critical care setting; but its use is closely related with some life threatening complications as nosocomial pneumonia and low cardiac performance. One of the most severe complications is called ventilator-associated lung injury (VALI) and it includes: Barotrauma, volutrauma, atelectrauma, biotrauma and oxygen-mediated toxic effects and it is related with an inflammatory response secondary to the stretching and recruitment process of alveoli within mechanical ventilation. The use of some protective ventilatory strategies has lowered the mortality rate 10% approximately.

La importancia de la asistencia mecánica ventilatoria (AMV) en la Unidad de Cuidados Intensivos (UCI) es indiscutible; sin embargo, su uso está ligado con complicaciones como neumonía nosocomial y deterioro del rendimiento cardiaco, que en algunas ocasiones ponen en peligro la vida del enfermo. Una de las complicaciones más graves es el daño pulmonar asociado a la ventilación mecánica (DPVM). El DPVM se caracteriza por la presencia de edema pulmonar rico en proteínas. Se recomienda establecer cierto número de estrategias de protección pulmonar (EPP) para prevenir este tipo de lesión. Una vez instituidas, las EPP han demostrado una disminución de la mortalidad de aproximadamente 10%.

Corportamiento clínico y manejo del cáncer gástrico avanzado / Behavior clinico and managings of the cancer gastric advanced

El presente estudio es descriptivo, prospectivo y transversal, el universo estuvo conformado por todos los pacientes que ingresaron al hospital Dr. Roberto Calderon de Managua, con sospecha de cáncer gástrico y aquellos pacientes que fueron recibidos procedentes de otros centros con el diagnóstico de cáncer gástrico. Los principales resultados obtenidos fueron: la media de edad fue de 52, 45 años con un intervalo mínimo-máximo (27-82), los casos se presentaron con mayor frecuencia en el sexo masculino (56.6 porciento). Los principales síntomas que aquejaron al momento del interrogatorio en orden de frecuencia fueron: perdida de peso y anorexia en el 90 porciento de los casos respectivamente, dolor epigástrico en el 86.6 porciento. vómito en 73.53 porciento. Las radiografías realizadas a los pacientes como parte de su evaluación general se encontraron normales en un 86.2 porciento, reportando metástasis en el 15.79 orciento de un total de 29 pacientes a quienes se logró realizar dicho estudio de imagen. En endoscopias digestivas altas se reportaron los hallagos de: el 76.6 porciento se encontraban en Borrmann III, el 16.6 porciento en Borrmann II, y el 6.6 porciento en Borrmann IV. La localización anatómica más frecuente fue el cuerpo gástrico 46.6 porciento seguido del cuerpo y el antro. En las tinciones de giemsa se identifcó Helicobacter pylori en el 53.53 porciento de los casos. El tipo histológico que se encontró con mayor frecuencia fue el adenocarcinoma pobremente diferenciado de células en anillo de sello 50 porciento. Los procedimiento realizados fueron gastrectomía subtotal en el 47.61 porciento y gastrectomía total 33.53 porcineto. El 16.6 porciento del total de pacientes recibieron por lo menos 1 ciclo de quimoterapia adyuvante Se concluyó que la mayoría de los pacientes se encuentran en etapas avanzadas de la enfermedad lo que hace que la sintomatología sea florida...