ABSTRACT
Las áreas críticas de atención médica, como las unidades de terapia intensiva (UTI), constituyen el escenario clínico donde se aplican métodos invasivos de soporte vital y maniobras de reanimación cardiopulmonar en pacientes cuya recuperabilidad potencial no se evalúa inicialmente. En éste trabajo se analiza una encuesta de opinión efectuada a 93 médicos no especialistas en terapia intensiva sobre el ingreso de pacientes irrecuperables a UTI, la necesidad de limitar el tratamiento a pacientes terminales y ciertos determinantes de la conducta médica en éstas circunstancias. Los resultados indicaron que la presencia frecuente de pacientes irrecuperables en UTI se debe fundamentalmente a exigencias familiares y la carencia de áreas asistenciales adecuadas para la contención del enfermo terminal, circunstancias que pueden favorecer el encarnizamiento terapeútico y la prolongación indefinida de la vida vegetativa. El acuerdo de los médicos en el establecimiento de límites en la atención médica de pacientes irrecuperables parece tener como factores determinantes la desprotección legal de nuestro país para el ejercicio de éstas prácticas y la falta de consenso social sobre éstos temas. El universo médico encuestado no visualiza como equivalentes moralmente la decisión de no actuar respecto de la de dejar de actuar (AU)
Subject(s)
Humans , Male , Female , Terminally Ill , Life Support Care/trends , Terminal Care/trends , Health Knowledge, Attitudes, Practice , Data Collection/classification , Palliative Care , Intensive Care Units/statistics & numerical data , Resuscitation Orders , Life Support Care/statistics & numerical data , Palliative Care/statistics & numerical data , Palliative Care/trends , Ethics, Medical , Right to Die , Patient Advocacy/statistics & numerical dataABSTRACT
Las áreas críticas de atención médica, como las unidades de terapia intensiva (UTI), constituyen el escenario clínico donde se aplican métodos invasivos de soporte vital y maniobras de reanimación cardiopulmonar en pacientes cuya recuperabilidad potencial no se evalúa inicialmente. En éste trabajo se analiza una encuesta de opinión efectuada a 93 médicos no especialistas en terapia intensiva sobre el ingreso de pacientes irrecuperables a UTI, la necesidad de limitar el tratamiento a pacientes terminales y ciertos determinantes de la conducta médica en éstas circunstancias. Los resultados indicaron que la presencia frecuente de pacientes irrecuperables en UTI se debe fundamentalmente a exigencias familiares y la carencia de áreas asistenciales adecuadas para la contención del enfermo terminal, circunstancias que pueden favorecer el encarnizamiento terapeútico y la prolongación indefinida de la vida vegetativa. El acuerdo de los médicos en el establecimiento de límites en la atención médica de pacientes irrecuperables parece tener como factores determinantes la desprotección legal de nuestro país para el ejercicio de éstas prácticas y la falta de consenso social sobre éstos temas. El universo médico encuestado no visualiza como equivalentes moralmente la decisión de no actuar respecto de la de dejar de actuar
Subject(s)
Humans , Male , Female , Life Support Care/trends , Health Knowledge, Attitudes, Practice , Data Collection/classification , Terminal Care/trends , Terminally Ill , Palliative Care , Life Support Care/statistics & numerical data , Ethics, Medical , Intensive Care Units/statistics & numerical data , Palliative Care/statistics & numerical data , Palliative Care/trends , Patient Advocacy/statistics & numerical data , Resuscitation Orders , Right to DieABSTRACT
BACKGROUND: Descriptive study of physical injuries and implemented organization from a nearby, unwarned university hospital after the July 18, 1994, bombing of the seven-story Argentine Israeli Mutual Association (AMIA) building in Buenos Aires. Data were obtained from hospital medical records. RESULTS: A total of 86 victims arrived at the emergency department, 2 victims were dead on arrival, 41 victims were admitted, and 43 victims with minor injuries were assisted and allowed to go home. The explosion caused a total of 86 deaths and left more than 200 people injured. Mortality rate among hospitalized survivors was 8.3% and among critically injured victims was 28.6%. CONCLUSION: The total collapse of a multiple-story building immediately kills most of its occupants. In the present study, the few surviving victims were located at the lower floors. The majority of hospitalized victims were outside the building at the moment of the blast. Rapid overcrowding of the emergency department with minor and moderate injuries that do not require hospitalization should be anticipated by disaster management plans. Centralization of severely injured patients in critical areas seems appropriate, because this method keeps major cases from spreading through different wards.
Subject(s)
Blast Injuries/diagnosis , Blast Injuries/therapy , Disaster Planning/organization & administration , Emergency Treatment/methods , Explosions , Triage/organization & administration , Adolescent , Adult , Aged , Aged, 80 and over , Argentina/epidemiology , Blast Injuries/classification , Blast Injuries/epidemiology , Child , Child, Preschool , Fatal Outcome , Female , Hospital Mortality , Hospitals, University , Humans , Injury Severity Score , Jews , Male , Middle Aged , Retrospective Studies , Survival Analysis , ViolenceABSTRACT
OBJECTIVES: To determine in hypothermic patients if a) the decrease in oxygen consumption (VO2) is exclusively dependent on the decrease in metabolic rate, or b) as a consequence of the greater hemoglobin affinity for oxygen, hypothermic tissues have impaired oxygen extraction. DESIGN: Clinical, prospective study; sequential measurements of oxygen-related variables during active core rewarming. SETTING: Intensive care unit of a university hospital. PATIENTS: Twelve patients (44 +/- 16 yrs of age) admitted to the intensive care unit with a core temperature of < 34 degrees C due to severe neurologic damage. INTERVENTIONS: Rewarming (with heated enemas, gastric infusions, and heated blankets) to increase body temperature at a rate of approximately 1 degree C/hr. Measurements of oxygen-related variables were performed at a baseline of 31.0 +/- 1.1 degrees C, and repeated at each 1 degree C increase to reach a core temperature of approximately 35 degrees C. MEASUREMENTS AND MAIN RESULTS: Oxygen-related variables of rewarmed patients were allocated into two groups, above or below the observed mean core temperature of 33.1 degrees C recorded for all measurements (n = 45). Comparison of the low core temperature group (31.1 +/- 1.4 degrees C; n = 20) with the high core temperature group (34.7 +/- 0.9 degrees C; n = 25) showed that the group with the lower core temperatures had a significant increase in VO2 index (67 +/- 22 vs. 103 +/- 38 mL/min/m2 [p < .001]), oxygen delivery index (183 +/- 73 vs. 290 +/- 123 mL/min/m2 [p < .001]), and the PO2 value at which hemoglobin was half-saturated with oxygen ([P50] 23 +/- 5.7 vs. 27.7 +/- 5.7 torr [3.0 +/- 0.7 vs. 3.6 +/- 0.7 kPa] [p < .02]). An increase in metabolic acidosis could be observed in the lower temperature group: arterial pH 7.47 +/- 0.15 vs. 7.34 +/- 0.13 (p < .01); base deficit -3.7 +/- 6.7 vs. -8.2 +/- 4.9 mEq/L (p < .02). The oxygen extraction ratio remained unchanged: 0.39 +/- 0.10 vs. 0.38 +/- 0.10 (NS). CONCLUSIONS: These data show that VO2 was reduced to half of normal values during hypothermia. Active core rewarming produced an average 4.5% increase in VO2 per 1 degree C that was characterized by the wide variation observed in this metabolic response between different patients and for individual cases. Despite the rightward shift of P50 observed during rewarming (mainly due to the Bohr effect), no change was reflected on the oxygen extraction ratio.
Subject(s)
Acidosis, Lactic/metabolism , Acidosis, Lactic/therapy , Blood Gas Analysis , Body Temperature , Brain Diseases/complications , Craniocerebral Trauma/complications , Hot Temperature/therapeutic use , Hypothermia/metabolism , Hypothermia/therapy , Oxygen Consumption , Acidosis, Lactic/diagnosis , Acidosis, Lactic/etiology , Acidosis, Lactic/physiopathology , Adolescent , Adult , Aged , Brain Diseases/surgery , Female , Hemodynamics , Humans , Hypothermia/diagnosis , Hypothermia/etiology , Hypothermia/physiopathology , Male , Middle Aged , Prospective StudiesABSTRACT
Oxygen delivery (DO2) and related variables were studied in eight dogs during severe untreated peritonitis induced by cecal ligation and perforation. The development of peritonitis was accompanied by abdominal fluid sequestration and significant increases in hemoglobin (Hgb), arterial oxygen content (CaO2), and P50. Changes in mixed venous PO2 (P-vO2), mixed venous saturation (S-vO2), DO2, oxygen uptake (VO2), cardiac index (CI), and arteriovenous O2 difference (C[a--v]O2) were not significant. When blood volume was returned to normal levels with dextran, CI rose and C(a--v)O2 decreased; P-vO2 increased and Hgb returned to baseline levels. In this animal model, sepsis and fluid sequestration produced an increase in blood O2 capacity and CaO2, which sustained DO2 and VO2. No changes were observed in P-vO2 or S-vO2. The hyperdynamic state of severe sepsis became evident only after reversing hemoconcentration by colloid infusion. The increase in P-vO2 and S-vO2 after volume loading is possibly related to primary septic mechanisms and/or to changes in DO2.
Subject(s)
Oxygen/metabolism , Peritonitis/metabolism , Animals , Blood Pressure , Cardiac Output , Dextrans/therapeutic use , Dogs , Hemoglobins , Oxygen Consumption , Peritonitis/drug therapy , Pulmonary Gas ExchangeABSTRACT
Se estudiaron variables hemodinamicas y metabolicas en 9 perros antes y despues de la induccion de una peritonitis grave, y tras la expansion del volumen sanguineo.Los animales mantuvieron el VO2 en base a hemoconcentracion en la primera etapa y por aumento del VM en la segunda para compensar la lesion celular septica.Se discute el significado de ambas situaciones
Subject(s)
Male , Female , Animals , Dogs , PeritonitisABSTRACT
Se estudiaron variables hemodinamicas y metabolicas en 9 perros antes y despues de la induccion de una peritonitis grave, y tras la expansion del volumen sanguineo.Los animales mantuvieron el VO2 en base a hemoconcentracion en la primera etapa y por aumento del VM en la segunda para compensar la lesion celular septica.Se discute el significado de ambas situaciones
Subject(s)
Male , Female , Animals , Dogs , PeritonitisABSTRACT
Captopril was tested as the treatment for a patient with primary pulmonary hypertension (PPH) and its effects were compared with those of hydralazine. Captopril induced a rise in pulmonary pressures and in intrapulmonary shunt; hydralazine lowered pulmonary resistances and increased paO2 and blood O2 transport. Prospective studies in PPH treated with captopril are recommended and evaluation of all drugs not only by hemodynamic but also respiratory and O2 transport measurements.
Subject(s)
Captopril/therapeutic use , Hemodynamics/drug effects , Hydralazine/therapeutic use , Hypertension, Pulmonary/physiopathology , Proline/analogs & derivatives , Respiration/drug effects , Adult , Female , Humans , Hypertension, Pulmonary/drug therapySubject(s)
Acute Disease , Electrocardiography , Hypothermia/physiopathology , Adult , Aged , Female , Humans , Hypothermia/etiology , Male , Middle AgedABSTRACT
Se presenta el caso de una paciente de 46 anos portadora de un carcinoma pulmonar con metastasis suprarrenales bilaterales que reemplazan casi totalmente las glandulas. El diagnostico se confirmo por la tomografia computada y los hallazgos necropsicos. Se trata de un caso poco comun de insuficiencia suprarrenal que reune un estado de colapso circulatorio junto a edemas. Se jerarquiza el rol de la falta de cortisol en la genesis de los fenomenos descriptos debido a que no pudo corregirse el shock con la administracion de cloruro de sodio en solucion al 0,9% o con la infusion de dopamina, pero si ocurrio luego de la administracion de hidrocortisona intravenosa
Subject(s)
Middle Aged , Humans , Female , Shock , Adrenocortical Hyperfunction , Adrenal Gland Neoplasms , Lung NeoplasmsSubject(s)
Adult , Middle Aged , Aged , Humans , Male , Female , Acute Disease , Electrocardiography , HypothermiaABSTRACT
Se presenta el caso de una paciente de 46 anos portadora de un carcinoma pulmonar con metastasis suprarrenales bilaterales que reemplazan casi totalmente las glandulas. El diagnostico se confirmo por la tomografia computada y los hallazgos necropsicos. Se trata de un caso poco comun de insuficiencia suprarrenal que reune un estado de colapso circulatorio junto a edemas. Se jerarquiza el rol de la falta de cortisol en la genesis de los fenomenos descriptos debido a que no pudo corregirse el shock con la administracion de cloruro de sodio en solucion al 0,9% o con la infusion de dopamina, pero si ocurrio luego de la administracion de hidrocortisona intravenosa
