Tromboembolia pulmonar masiva de repetición tratada con 2 fibrinolisis consecutivas / Recurrent massive pulmonary thromboembolism treated with two consecutive administrations of a fibrinolytic agent

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[Cardiac Tamponade after on a guide changing of a central venous catheter for total parenteral nutrition. Could it be avoided?]. / Taponamiento cardíaco tras cambio de catéter venoso central, sobre guía, para nutrición parenteral total. Lo podemos evitar?

Catheterization of central veins is a routine process, especially in severely-ill patients. It is a technique associated with multiple potential complications, fortunately infrequent, depending on the skill with which it is performed. Cardiac blockade is one of these infrequent complications with a high mortality. We describe a case in which suspicion, early diagnosis, and immediate manipulative treatment allowed a successful recovery of the patient. In addition, the literature is reviewed and possible mechanisms involved in these episodes are discussed.

Taponamiento cardíaco tras cambio de catéter venoso central, sobre guía, para nutrición parenteral total. ¿Lo podemos evitar? / Cardiac blockade after changing central venous catheter, on a guide, for total parenteral nutrition. Can it be avoided?

La cateterización de venas centrales es un proceso rutinario, sobre todo en enfermos graves. Es una técnica en la que están descritas múltiples complicaciones, afortunadamente no muy frecuentes, y en relación con la pericia del que la realiza. El taponamiento cardíaco es una de estas infrecuentes complicaciones, con muy elevada mortalidad. Describimos un caso en el que por sospecha, diagnóstico precoz y tratamiento inmediato se siguió de éxito en las maniobras de recuperación del enfermo. Asimismo, se revisa la literatura y se analizan los posibles mecanismos de estos episodios (AU)

Catheterization of central veins is a routine process, especially in severely-ill patients. It is a technique associated with multiple potential complications, fortunately infrequent, depending on the skill with which it is performed. Cardiac blockade is one of these infrequent complications with a high mortality. We describe a case in which suspicion, early diagnosis, and immediate manipulative treatment allowed a successful recovery of the patient. In addition, the literature is reviewed and possible mechanisms involved in these episodes are discussed (AU)

[The administration of 20 ppm of inhaled nitric oxide produces a faster response than the inhalation of 5 ppm in adult respiratory distress syndrome]. / La administración de 20 ppm de óxido nítrico inhalado produce una respuesta más rápida que la inhalación de 5 ppm en el síndrome de distrés respiratorio del adulto.

OBJECTIVES: To compare the effects of 5 and 20 ppm of nitric oxide, evaluating time until response for each dose, in patients with adult respiratory distress syndrome (ARDS). PATIENTS AND METHODS: The study was prospective, controlled and random. Fifteen patients assigned to two groups received either 5 ppm (8 patients) or 20 ppm (7 patients) from November 96 to July 97. The main variables analyzed were PaO2/FiO2 and pulmonary vascular resistance index. We also studied etiology, severity of pulmonary damage as reflected by the Lung Injury Score, age, sex, Apache II prognostic score and exitus. Outcome was considered good if PaO2/FiO2 increased and/or pulmonary vascular resistance index decreased by more than 30% from the initial level (before inhalation of nitric oxide). RESULTS: The mean lung injury score was 2.9 +/- 0.4 and the two groups were homogeneous. Time until response to nitric oxide was significantly less in the 20 ppm group. Both PaO2/FiO2 and pulmonary vascular resistance index improved significantly in both groups whereas Qs/Qt improved only in the 20 ppm group. We also found that cardiac index and oxygen transport increased, the latter significantly only in the 20 ppm group. NO2 formation was less than 2 ppm and methemoglobin levels did not rise above 2%. CONCLUSIONS: Inhaled nitric oxide significantly improves oxygenation and decreases pulmonary vascular resistance without altering systemic vascular resistance during treatment of ARDS. The final outcomes were similar for both doses, but the 20 ppm dose produced a significantly faster response as well as a significant decrease in Qs/Qt.

La administración de 20 ppm de óxido nítrico inhalado produce una respuesta más rápida que la inhalación de 5 ppm en el síndrome de distrés respiratorio del adulto / An inhaled nitric oxide dose of 20 ppm produces a faster response than 5 ppm in adult respiratory distress syndrome

Objetivos. Comparar los efectos respectivos de 5 y 20 partes por millón (ppm) evaluando el tiempo de respuesta de ambas dosis, en pacientes con síndrome de distrés respiratorio del adulto.Métodos. El estudio fue prospectivo, controlado y aleatorio. Se estudió a 15 pacientes divididos en dos grupos, que recibían dosis de 5 ppm (grupo 5 ppm: 8 pacientes) o bien de 20 ppm (grupo 20 ppm: 7 pacientes), entre noviembre de 1996 y julio de 1997. Las variables principales analizadas fueron el índice PaO2/FiO2 y el índice de resistencias vasculares pulmonares. También se estudiaron la etiología, la gravedad de la lesión pulmonar según la Lung Injury Score (LIS), la edad, el sexo, el índice pronóstico APACHE II y la mortalidad. Se consideró resultado positivo el aumento del PaO2/FiO2 y/o la disminución del índice de resistencias vasculares pulmonares en más del 30 por ciento de los valores previos a la inhalación de NO.Resultados. El valor medio del LIS fue de 2,9 ñ 0,4. Los dos grupos eran homogéneos. El tiempo de respuesta al NO fue significativamente inferior en el grupo 20 ppm. Tanto el PaO2/FiO2 como el índice de resistencias vasculares pulmonares mejoraron significativamente en los dos grupos, y el Qs/Qt sólo en el grupo 20 ppm. También se observó aumento en el índice cardíaco y transporte de O2, que fue significativo sólo en el grupo 20 ppm. La formación de NO2 fue inferior a 2 ppm y la metahemoglobina no superó el 2 por ciento.Conclusiones. La inhalación de NO produjo mejoría significativa en la oxigenación y disminuyó significativamente las resistencias vasculares pulmonares, sin alterar las resistencias vasculares sistémicas, durante el tratamiento del síndrome de distrés respiratorio del adulto. Los efectos finales de ambas dosis fueron similares, pero las dosis de 20 ppm produjeron una respuesta significativamente más temprana y una disminución del Qs/Qt también significativa (AU)

[Comparative study of percutaneous tracheotomy and conventional surgical tracheotomy in patients with prolonged intubation]. / Estudio comparativo entre la traqueotomía percutánea y la traqueotomía convencional quirúrgica en pacientes con intubación prolongada.

BACKGROUND: Percutaneous tracheotomy (PT) has become an alternative to conventional surgical tracheotomy (CST) in recent years. Our aim was to compare the advantages and disadvantages of the two techniques in our intensive care unit (ICU). PATIENTS AND METHODS: Two patient groups were compared. Sixty underwent PT and 47 underwent CST, and all were admitted to the ICU between May 1995 and August 1997. PT was performed in 49 by way of progressive dilations, and 11 were performed by Griggs' method using a dilator. Variables studied were age, sex, reason for admission, APACHE II upon admission to the ICU, duration of technique, and immediate and late complications. Statistical analysis was provided by applying a Student t test to contrast quantitative variables and a chi-squared test to compare proportions. RESULTS: The following variables were significantly different. APACHE II upon admission was 18 +/- 5 in the PT group and 15 +/- 6 in the CST group (p < 0.002). Duration of the procedure was 15 +/- 4 minutes in the PT group and 36 +/- 11 in the CST group (p < 0.005). Complications after tracheotomy in PT group patients consisted of 1 false line during a change of cannula and 1 late tracheoesophageal fistula. Complications in the CST group included 16 episodes of slight bleeding, 9 stoma infections, 3 cases of pneumothorax, 2 of bad scarring of the stoma and 1 late fistula (p < 0.005). Time of follow-up was 41 to 76 days for PT patients and 32 to 51 days for CST patients. CONCLUSIONS: PT is a fast, simple procedure that is easy to manage and requires fewer resources (operating theater, personnel and equipment) and causes fewer medium-term complications than does CST.

[Chylothorax secondary to blunt thoracic trauma. Report of 6 cases]. / Quilotórax secundario a traumatismo torácico cerrado. A propósito de 6 casos.

Chylothorax is a rare condition that even more rarely arises as a result of closed thoracic trauma. We report a series of 6 patients who suffered chylothorax after closed trauma, who were diagnosed early and treated conservatively. Either total parenteral feeding or adjusted enteral feeding, depending with circumstances, was started early such that complications from chylothorax were few. Surgery was required in only one case, and outcomes were satisfactory in all patients, none of whom died.

[Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome]. / Ventilación pulmonar independiente sincronizada en el tratamiento del síndrome de distrés respiratorio del adulto.

INTRODUCTION: Synchronized independent lung ventilation (SILV) is an effective mode of mechanical ventilation for treating both unilateral and bilateral pulmonary lesions. Oxygenation improves with an increase in the ventilation/perfusion ratio and also diminishes the risk of barotrauma. We describe our broad experience with this technique. Our main objective was to confirm whether SILV is able to improve the alveolar-arterial oxygen difference [P(A-a)O2] of patients with severe adult respiratory distress syndrome (ARDS) in whom conventional mechanical ventilation has not brought about improvement after being used for over 48 hours. PATIENTS AND METHODS: We carried out a descriptive, open, controlled prospective study of 45 patients with severe ARDS, enrolled from among 68 who underwent treatment with SILV. The most frequent cause of ARDS in our study was multiple trauma. The patients diagnosed of ARDS who did not improve with conventional mechanical ventilation were treated with SILV. Clinical characteristics and mortality are described. APACHE II scores, PAOA-aO2, dynamic distensibility were analyzed before and after SILV. The results of SILV were considered good if PA-aO2 improved at least 30% within 48 hours, with no increase in distensibility. RESULTS: No complications due to the technique were observed. Twenty-two patients (48.8%) died, 18 as a result of multiple organ failure and only one (4.5%) because of hypoxia. The improvements in APACHE II and (PA-aO2 were statistically significant, while distensibility did not change. The result was defined as good in most cases (n = 34, 83.8%). CONCLUSIONS: SILV is useful for providing ventilatory support when ARDS fails to improve with conventional mechanical ventilation. Clear improvement in respiratory function was observed, with significant decrease in PA-aO2 and no change in distensibility. SILV is a safe technique with few complications and can be managed by the intensive care unit nursing staff.

[Hydropneumothorax secondary to enteral feeding tube]. / Hidroneumotórax secundario a sonda de nutrición enteral.

The placement of naso-gastric tubes is a routing procedure in Intensive Care Units. Their basic indications are the aspiration of gastric contents, as well as the enteral nutrition of the patients. Despite this being a simple technique, it is not exempt of complications, some of which are very serious, which should be kept in mind in order to prevent them and to diagnose them early. We describe a case of hydro-pneumothorax, secondary to the placement of a naso-gastric tube for enteral nutrition.

[Enteral nutrition in ICU patients on a high-protein diet]. / Nutrición enteral en pacientes de UCI con dieta hiperproteica.

BASIS: The need for nutritional support is at present beyond question, while the use of early enteral nutrition in critical patients admitted to Intensive Care Units is increasingly common and would appear to offer a set of advantages as nutritional support. PATIENTS: Of a total of 26 consecutive enteral nutrition patients, 22 were studied prospectively (84.6%), and, through a nasal-gastric probe, were administered early high protein enteral polymeric diet with 25% of total calorific value from proteins, for an average of 10 days. The other four (15.4%) did not enter the study, according to the exclusion criteria established, and so were not taken into account in the statistics. METHOD: A design was followed in which the diet was administered progressively until reaching 30 ml/kg/day, in a maximum of three days, during which aspects were analyzed dealing with tolerance and ease of use, on the one hand, and other metabolic and nutritional aspects on the other. Analytical controls were carried out on days 0, 4, 8 and 12. Tolerance and adverse effects were monitored continuously. RESULTS: During the study, one of the twenty-two patients died (4.54%): the other 21 remained alive. In analysis of the metabolic and nutritional parameters, improvement was obtained in all those expected to reach normal levels, with p < 0.001 (glucose, prealbumin, TF, RBP, Zn, Mg and P). Of particular note was the evolution of the nitrogen balance (p < 0.001 and r = 0.77). As to tolerance, diarrhea appeared in two patients (9.09%), ileus in one (4.5%): no cases were detected of abdominal distension, nausea or vomiting. In no case was diet suspended for causes attributable to the enteral nutrition, nor was any therapeutic manipulation required. CONCLUSIONS: Excellent tolerance of enteral nutrition was obtained, with almost no complications associated with its use, despite the gravity of the patients (APACHE 14). On the other hand, an improvement was obtained in metabolic and nutritional parameters, with the particular significance of the nitrogen balance.