Incidencia, características y evolución del barotrauma durante la ventilación mecánica con apertura pulmonar / Incidence, characteristics and outcome of barotrauma during open lung ventilation

Objetivo: Describir la incidencia y principales características clínicas del barotrauma durante la ventilación mecánica con apertura pulmonar. Diseño: Estudio retrospectivo, observacional, descriptivo, en 100 pacientes con insuficiencia respiratoria aguda e infiltrados pulmonares bilaterales. Intervenciones: 1) maniobra de reclutamiento pulmonar (MRP) con presión de ventilación fija e incrementos progresivos de presión positiva al final de la espiración (PEEP), seguida de decrementos escalonados hasta establecer la PEEP de apertura en el valor asociado a la máxima distensibilidad respiratoria; 2) ventilación asistida/controlada por presión ajustada para un volumen tidal de 6-8ml/kg; y 3) radiografía de tórax después de la MRP y diariamente mientras persistió la insuficiencia respiratoria. Resultados: Nueve pacientes, 7 con neumonía y 2 con trauma torácico, desarrollaron barotrauma (2 enfisema subcutáneo y 7 neumotórax), lo cual supuso una incidencia total del 9% y del 16% en aquellos pacientes con lesión pulmonar primaria. En 7 pacientes fue tan solo de un hallazgo radiológico; en los otros dos, se manifestó como un neumotórax bilateral y a tensión, cursando con hipoventilación pulmonar. Únicamente en estos dos casos se modificó la estrategia ventilatoria. No hubo diferencias en las presiones ni en los volúmenes respiratorios entre pacientes con o sin barotrauma. La mortalidad fue similar en ambos grupos. Conclusiones: El barotrauma resultó una complicación exclusiva de pacientes con lesión pulmonar primaria, en los que tuvo una incidencia elevada. En la mayoría de las ocasiones fue un hallazgo radiológico sin manifestaciones clínicas, manteniéndose la ventilación con apertura pulmonar. Su aparición no se relacionó con presiones ni volúmenes respiratorios mayores, ni se asoció a mayor mortalidad (AU)

Objective: To describe the incidence and main clinical characteristics of barotrauma during open lung ventilation (OLV). Design: A retrospective, observational, descriptive study was made of 100 patients with acute respiratory failure and bilateral pulmonary infiltrates. Interventions: 1) A lung recruitment maneuver (LRM) with fixed ventilation pressure and progressive positive end-expiratory pressure (PEEP) elevations was carried out, followed by stepwise decreases until establishing open-lung PEEP at the value associated to maximum respiratory compliance; 2) assisted/controlled pressure ventilation to achieve a tidal volume of 6-8ml/kg; and 3) chest X-rays after LRM and daily for as long as respiratory failure persisted. Results: Nine patients, 7 with pneumonia and 2 with chest trauma, developed barotrauma (2 subcutaneous emphysemas and 7 cases of pneumothorax), representing an overall incidence of 9% and 16% in patients with primary lung injury. In 7 patients barotrauma was only a radiological finding; in the other 2 patients, it manifested as bilateral and tension pneumothorax, inducing pulmonary hypoventilation without hemodynamic impairment. Only in these two cases was the ventilatory strategy modified. There were no differences in the airway pressures or volumes between patients with and without barotrauma. Mortality was similar in both groups. Conclusions: Barotrauma was an exclusive complication of patients with primary lung injury, and the incidence in this group was high. In most cases, there were only radiological findings without clinical significance that did not require the suspension of OLV. Barotrauma was neither related to high pressures and volumes nor associated with increased mortality (AU)

Cambios respiratorios y hemodinámicos durante una maniobra de reclutamiento pulmonar mediante incrementos y decrementos progresivos de PEEP / Respiratory and hemodynamic changes during lung recruitment maneuvering through progressive increases and decreases in PEEP level

Objetivo: Estudiar los cambios respiratorios y hemodinámicos durante una maniobra de reclutamiento pulmonar (MRP) mediante incrementos y decrementos progresivos de PEEP. Diseño y ámbito: Estudio retrospectivo en una UCI de 17 camas. Pacientes: Un total de 21 pacientes con insuficiencia respiratoria aguda e infiltrados pulmonares bilaterales. Intervención: MRP consistente en incrementos progresivos de PEEP (4cmH2O cada 3 minutos), con presión de ventilación fija, hasta alcanzar un valor máximo de 36cmH2O de PEEP (rama ascendente), seguida de decrementos progresivos (2cmH2O cada 3 minutos) hasta establecer la PEEP de apertura en el valor asociado a la máxima distensibilidad del sistema respiratorio (Dsr) (rama descendente). La monitorización hemodinámica se realizó de forma continua con una sonda ecodoppler esofágica. Resultados: La Dsr disminuyó gradualmente en la rama ascendente de la MRP y aumentó de forma progresiva superando el valor inicial al establecer la PEEP de apertura en la rama descendente, reduciéndose la presión de ventilación y aumentando la relación SpO2/FiO2. Los cambios hemodinámicos consistieron fundamentalmente en una disminución del gasto cardiaco y de la precarga del ventrículo izquierdo, junto con un aumento de la frecuencia y de la contractilidad cardiaca. A niveles equiparables de PEEP y presión media en vía aérea, estos cambios fueron más intensos durante la rama descendente. Conclusiones: 1) La realización de la MRP incrementó la Dsr mejorando la oxigenación y disminuyendo la presión de ventilación; 2) la principal consecuencia hemodinámica fue la disminución del gasto cardiaco y de la precarga ventricular izquierda; 3) la afectación hemodinámica desigual en ambas ramas, a niveles equiparables de PEEP y presión media en vía aérea, puso de manifiesto que, junto a la presión intratorácica, otros factores como la Dsr y la hipercapnia pudieron influir en las consecuencias hemodinámicas en este tipo de MRP (AU)

Objective: To evaluate the respiratory and hemodynamic changes during lung recruitment maneuvering (LRM) through stepwise increases and decreases in PEEP level. Design and setting: A retrospective study in a 17-bed ICU was carried out. Patients: Twenty-one patients with acute respiratory failure and bilateral pulmonary infiltration. Intervention: LRM was carried out, consisting of stepwise increases in PEEP (4cmH2O every 3minutes), with fixed ventilation pressure, until reaching a maximal value of 36cmH2O PEEP (ascending branch), followed by progressive decreases in PEEP (2cmH2O every 3minutes) until establishing the open-lung PEEP at the value associated to maximum respiratory compliance (Crs) (descending branch). Continuous hemodynamic monitoring was performed using an esophageal echodoppler probe. Results: Crs gradually decreased in the ascending branch of the LRM, and progressively increased surpassing the initial value after establish the open-lung PEEP in the descending branch, reducing the ventilation pressure and increasing the SpO2/FiO2 ratio. Hemodynamic changes primarily consisted of a fall in cardiac output and left ventricular preload, together with an increased heart rate and cardiac contractility. At comparable levels of PEEP and mean airway pressure, these changes were more pronounced during the descending branch of the LRM. Conclusions: 1) LRM increased Crs, improving oxygenation and decreasing ventilation pressure; 2) the main hemodynamic consequence was the drop in cardiac output and left ventricular preload; and 3) the unequal hemodynamic derangement in both branches, at the same level of PEEP and mean airway pressure, showed that, along with intrathoracic pressure, other factor such as Crs and hypercapnia may have influenced the hemodynamic consequences of this type of LRM (AU)

[Incidence, characteristics and outcome of barotrauma during open lung ventilation]. / Incidencia, características y evolución del barotrauma durante la ventilación mecánica con apertura pulmonar.

OBJECTIVE: To describe the incidence and main clinical characteristics of barotrauma during open lung ventilation (OLV). DESIGN: A retrospective, observational, descriptive study was made of 100 patients with acute respiratory failure and bilateral pulmonary infiltrates. INTERVENTIONS: 1) A lung recruitment maneuver (LRM) with fixed ventilation pressure and progressive positive end-expiratory pressure (PEEP) elevations was carried out, followed by stepwise decreases until establishing open-lung PEEP at the value associated to maximum respiratory compliance; 2) assisted/controlled pressure ventilation to achieve a tidal volume of 6-8 ml/kg; and 3) chest X-rays after LRM and daily for as long as respiratory failure persisted. RESULTS: Nine patients, 7 with pneumonia and 2 with chest trauma, developed barotrauma (2 subcutaneous emphysemas and 7 cases of pneumothorax), representing an overall incidence of 9% and 16% in patients with primary lung injury. In 7 patients barotrauma was only a radiological finding; in the other 2 patients, it manifested as bilateral and tension pneumothorax, inducing pulmonary hypoventilation without hemodynamic impairment. Only in these two cases was the ventilatory strategy modified. There were no differences in the airway pressures or volumes between patients with and without barotrauma. Mortality was similar in both groups. CONCLUSIONS: Barotrauma was an exclusive complication of patients with primary lung injury, and the incidence in this group was high. In most cases, there were only radiological findings without clinical significance that did not require the suspension of OLV. Barotrauma was neither related to high pressures and volumes nor associated with increased mortality.

[Respiratory and hemodynamic changes during lung recruitment maneuvering through progressive increases and decreases in PEEP level]. / Cambios respiratorios y hemodinámicos durante una maniobra de reclutamiento pulmonar mediante incrementos y decrementos progresivos de PEEP.

OBJECTIVE: To evaluate the respiratory and hemodynamic changes during lung recruitment maneuvering (LRM) through stepwise increases and decreases in PEEP level. DESIGN AND SETTING: A retrospective study in a 17-bed ICU was carried out. PATIENTS: Twenty-one patients with acute respiratory failure and bilateral pulmonary infiltration. INTERVENTION: LRM was carried out, consisting of stepwise increases in PEEP (4 cmH(2)O every 3 minutes), with fixed ventilation pressure, until reaching a maximal value of 36 cmH(2)O PEEP (ascending branch), followed by progressive decreases in PEEP (2 cmH(2)O every 3 minutes) until establishing the open-lung PEEP at the value associated to maximum respiratory compliance (Crs) (descending branch). Continuous hemodynamic monitoring was performed using an esophageal echodoppler probe. RESULTS: Crs gradually decreased in the ascending branch of the LRM, and progressively increased surpassing the initial value after establish the open-lung PEEP in the descending branch, reducing the ventilation pressure and increasing the SpO(2)/FiO(2) ratio. Hemodynamic changes primarily consisted of a fall in cardiac output and left ventricular preload, together with an increased heart rate and cardiac contractility. At comparable levels of PEEP and mean airway pressure, these changes were more pronounced during the descending branch of the LRM. CONCLUSIONS: 1) LRM increased Crs, improving oxygenation and decreasing ventilation pressure; 2) the main hemodynamic consequence was the drop in cardiac output and left ventricular preload; and 3) the unequal hemodynamic derangement in both branches, at the same level of PEEP and mean airway pressure, showed that, along with intrathoracic pressure, other factor such as Crs and hypercapnia may have influenced the hemodynamic consequences of this type of LRM.

Complicación fatal tras una paracentesis diagnóstica: hematoma de la vaina de los rectos / A fatal case of diagnostic paracentesis: hematoma of the rectus abdominis

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Hemorragia digestiva secundaria a un leiomiosarcoma de íleon: tratamiento laparoscópico / Digestive hemorrhage secondary to leiomyosarcoma of the ileum: laparoscopic management

Las neoplasias malignas del intestino delgado representan únicamente el 2 por ciento de los tumores gastrointestinales. En su mayoría corresponden a adenocarcinomas y tumores carcinoides. Los tumores originados en la musculatura lisa intestinal se engloban dentro de la denominación de tumores estromales. Predominantemente se localizan en yeyuno e íleon. El tratamiento de esta entidad sigue siendo fundamentalmente quirúrgico, aunque su tratamiento laparoscópico sólo ha sido comunicado de forma ocasional. Describimos un caso de leiomiosarcoma de íleon cuyo tratamiento quirúrgico consistió en una resección laparoscópica (AU)