Plasmapheresis and other extracorporeal filtration techniques in critical patients / Plasmaféresis y otras técnicas de depuración extracorpórea en pacientes críticos

Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients

La plasmaféresis es una técnica extracorpórea mediante la cual se procede a la eliminación de macromoléculas del plasma que se consideran mediadores de procesos patológicos. En este artículo se revisan los aspectos técnicos, las principales indicaciones en las patologías que suelen motivar ingreso en la Unidad de Cuidados Intensivos y las potenciales complicaciones de la plasmaféresis. Así mismo, se incluye una revisión de otras técnicas de depuración extracorpórea, tales como las columnas de fijación de endotoxinas y otros procedimientos que persiguen la eliminación de citoquinas o la inmunomodulación del proceso inflamatorio en el paciente crítico

Plasmapheresis and other extracorporeal filtration techniques in critical patients.

Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients.

Intraventricular hemorrhage treated with intraventricular fibrinolysis. A 10-year experience

Purpose We evaluate the results and complications of our intraventricular fibrinolysis protocol. Material and methods A retrospective analysis was made of the cases of intraventricular hemorrhage with 13-bed Intensive Care Unit. Graeb score 6 or above subjected to intraventricular fibrinolysis. We gathered demographic parameters, clinical risk scores, tomography data and case histories showing neurological status and complications related to intraventricular treatment. The results between those who died and the survivors were compared. Results Intraventricular fibrinolysis was performed in 42 patients (69% males) with intraventricular hemorrhage. The average age was 58.36 years (SD 16.67), with a median APACHE II score of 17.5 (r 3–29). A total of 16.7% were receiving acenocoumarol, and 7.1% were on antiplatelet drugs. The median Glasgow Coma Score at the start of treatment was 8 (r 3–13). The median Graeb score was 9 (r 6–12), and was severe (Graeb 9–12) in almost 62%. In turn, 26.2% of the patients developed ventriculitis, and there was further bleeding in 7.1%. Death occurred in 50% of the cases. None of the analyzed variables were significantly related to increased mortality. In the 21 survivors, the Glasgow Outcome Score at 3 months was 2 in 23.8% of the cases, 3 in 28.57%, 4 in 23.8% and 5 in 28.57% of the patients. Conclusions Intraventricular fibrinolysis does not appear to involve a high rate of complications, and may result in lesser mortality, with a better functional outcome after three months than that estimated and published in the literature in reference to intraventricular hemorrhage (AU)

Objetivo Evaluar los resultados y complicaciones de un protocolo de fibrinólisis intraventricular empleado durante 10 años. Ámbito de aplicación y métodos Servicio de Medicina Intensiva de 13 camas. Análisis retrospectivo de nuestra base prospectiva de pacientes con hemorragia intraventricular con Graeb mayor de 5 tratados con fibrinólisis intraventricular. Registramos datos demográficos, escalas de gravedad, datos tomográficos y evolutivos neurológicos, y complicaciones relacionadas con la fibrinólisis. Comparamos los resultados entre fallecidos y supervivientes. Resultados Recibieron fibrinolíticos intraventriculares 42 pacientes (69% varones) con hemorragia intraventricular. La edad media fue 58,36 años (DE 16,67), con una mediana de APACHE II de 17,5 (rango 3-29). El 16,7% tomaban acenocumarol y el 7,1% estaban en tratamiento antiagregante. La mediana del Glasgow Coma Score en el momento de inicio de la fibrinólisis fue de 8 (rango 3-13), y la mediana de Graeb fue 9 (rango 6-12). Más del 62% de las hemorragias fueron clasificadas como graves (Graeb 9-12). Se complicaron con ventriculitis el 26,2% y con sangrado el 7,1%. Falleció el 50% de la serie. Ninguna de las variables analizadas se relacionó de modo significativo con la mortalidad. De los 21 supervivientes, el Glasgow Out come Score a los 3 meses fue de 2 en el 23,8%, de 3 en el 28,57%, de 4 en el 23,8% y de 5 en el 28,57%.ConclusionesLa fibrinólisis intraventricular no parece asociar una alta tasa de complicaciones, y puede contribuir a una menor mortalidad con mejor resultado funcional a los 3 meses que la estimada y publicada en la hemorragia intraventricular (AU)

Intraventricular hemorrhage treated with intraventricular fibrinolysis. A 10-year experience.

PURPOSE: We evaluate the results and complications of our intraventricular fibrinolysis protocol. MATERIAL AND METHODS: A retrospective analysis was made of the cases of intraventricular hemorrhage with 13-bed Intensive Care Unit. Graeb score 6 or above subjected to intraventricular fibrinolysis. We gathered demographic parameters, clinical risk scores, tomography data and case histories showing neurological status and complications related to intraventricular treatment. The results between those who died and the survivors were compared. RESULTS: Intraventricular fibrinolysis was performed in 42 patients (69% males) with intraventricular hemorrhage. The average age was 58.36 years (SD 16.67), with a median APACHE II score of 17.5 (r 3-29). A total of 16.7% were receiving acenocoumarol, and 7.1% were on antiplatelet drugs. The median Glasgow Coma Score at the start of treatment was 8 (r 3-13). The median Graeb score was 9 (r 6-12), and was severe (Graeb 9-12) in almost 62%. In turn, 26.2% of the patients developed ventriculitis, and there was further bleeding in 7.1%. Death occurred in 50% of the cases. None of the analyzed variables were significantly related to increased mortality. In the 21 survivors, the Glasgow Outcome Score at 3 months was 2 in 23.8% of the cases, 3 in 28.57%, 4 in 23.8% and 5 in 28.57% of the patients. CONCLUSIONS: Intraventricular fibrinolysis does not appear to involve a high rate of complications, and may result in lesser mortality, with a better functional outcome after three months than that estimated and published in the literature in reference to intraventricular hemorrhage.

Manejo del síndrome posparada cardíaca / Managing the post-cardiac arrest syndrome

Desde el advenimiento de la resucitación cardiopulmonar (RCP), hace más de 40 años, se ha conseguido que cada vez una mayor proporción de pacientes con parada cardiorrespiratoria logren la recuperación de la circulación espontánea (RCE). Sin embargo, la mayoría de estos pacientes fallecen en los primeros días tras su ingreso en las unidades de cuidados intensivos (UCI), y esta situación no ha mejorado en estos años. La mortalidad de estos pacientes se asocia en gran medida a daño cerebral. Posiblemente, el reconocimiento de que la RCP no se acaba con la RCE, sino con el retorno de la función cerebral normal y la estabilización total del paciente, nos ayudará a mejorar el tratamiento terapéutico de estos pacientes en las UCI. En este sentido, parece más apropiado el término «resucitación cardiocerebral», como proponen algunos autores. Recientemente, el Internacional Liaison Committee on Resuscitation (ILCOR) ha publicado un documento de consenso sobre el «síndrome posparada cardíaca» y diversos autores han propuesto que los cuidados posparada se integren como un quinto eslabón de la cadena de supervivencia, tras la alerta precoz, la RCP precoz por testigos, la desfibrilación precoz y el soporte vital avanzado precoz. El manejo terapéutico de los pacientes que recuperan la circulación espontánea tras las maniobras de RCP basada en medidas de soporte vital y una serie de actuaciones improvisadas basadas en el «juicio clínico» puede que no sea la mejor forma de tratar a los pacientes con «síndrome posparada cardíaca». Estudios recientes indican que el tratamiento de estos pacientes mediante protocolos guiados por objetivos -incluyendo las medidas terapéuticas que han demostrado su eficacia, como la hipotermia terapéutica inducida leve y la revascularización precoz, cuando esté indicada- puede mejorar notablemente el pronóstico de éstos. Dado que en el momento actual no existe un protocolo basado en la evidencia universalmente aceptado, el Comité Directivo del Plan Nacional de RCP de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), tras una revisión exhaustiva de la literatura científica sobre el tema, seguida de una discusión en línea entre todos los miembros del comité y una reunión de consenso, ha elaborado el presente documento con la intención de que pueda servir como base para el desarrollo de protocolos locales en las diferentes UCI de nuestro país, teniendo en cuenta sus medios y sus características propias (AU)

Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the «Post-Cardiac Arrest Syndrome» and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on «clinical judgment» might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics (AU)

[Managing the post-cardiac arrest syndrome. Directing Committee of the National Cardiopulmonary Resuscitation Plan (PNRCP) of the Spanish Society for Intensive Medicine, Critical Care and Coronary Units (SEMICYUC)]. / Manejo del síndrome posparada cardíaca. Comité Directivo del Plan Nacional de Resuscitación Cardiopulmonary de la SEMICYUC (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias).

Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the "Post-Cardiac Arrest Syndrome" and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on "clinical judgment" might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics.

La resucitación cardiopulmonar en el hospital: recomendaciones 2005 / Cardiopulmonary resuscitation in thehospital: recommendations 2005

Las paradas cardíacas hospitalarias representan un problema de primera magnitud. Se considera que entre un 0,4% y un 2% de los pacientes ingresados precisan de las técnicas de resucitación cardiopulmonar (RCP). La mitad de estas paradas se producen fuera de las Áreas de Críticos y en la actualidad, en el mejor de los casos, sólo 1 de cada 6 pacientes tratados sobrevive y puede ser dado de alta. Existe la evidencia de que pueden disminuirse la mortalidad y las secuelas que originan las paradas cardiorrespiratorias si se disminuyen los retrasos en la respuesta asistencial, con la optimización de la "Cadena de la Supervivencia Hospitalaria". Es decir, con estrategias dirigidas a: a) la identificación y tratamiento temprano de las situaciones susceptibles de desencadenar una parada cardíaca; b) la detección precoz de la parada cardiorrespiratoria; c) la aplicación sin tardanza de la RCP básica; d) la desfibrilación temprana; e) el inicio en muy pocos minutos de la RCP avanzada, y f) el traslado asistido e ingreso en la Unidad de Cuidados Intensivos. La desfibrilación temprana es la "llave para la supervivencia"; los trastornos del ritmo son la causa desencadenante más frecuente de la parada cardíaca, aunque sólo en una de cada cuatro paradas hospitalarias se documenta una fibrilación ventricular. En esta situación cada minuto de retraso en realizar la desfibrilación disminuye las posibilidades de sobrevivir en un 7%-10%. En los últimos años se han introducido en los hospitales mecanismos para mejorar la respuesta a las paradas cardíacas. A pesar del camino recorrido, el esfuerzo no puede considerarse suficiente. Sirva de ejemplo que nuestros hospitales tendrían problemas para acreditarse si se le aplicaran los estándares contemplados por la Joint Commission for the Accreditation of Heathcare Organizations (JCAHO). El Plan Nacional de RCP de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), en colaboración con la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC) ha elaborado estas recomendaciones, con el fin de contribuir a disminuir la mortalidad, secuelas y costes que originan las paradas cardíacas hospitalarias. En ellas también se recogen las directrices realizadas por las Sociedades Científicas Internacionales, en concreto por la International Liaison Committee on Resuscitation (ILCOR), que agrupa prácticamente todas las organizaciones dedicadas a la resucitación a nivel mundial, incluido el European Resuscitation Council (ERC), que es la organización que adapta estas recomendaciones a nuestro ámbito y es en las que se basan las del Plan Nacional de RCP de la SEMICYUC. Además, en su elaboración se ha seguido la línea marcada, en unas recientes recomendaciones, por el Resuscitation Council del Reino Unido

Hospital cardiac arrest represent a first magnitude problem. It is considered that between 0.4% and 2% of the patients admitted require Cardiopulmonary Resuscitation (CRP) techniques. Half of these arrests are produced outside of the critical areas and presently, in the best of the cases, only 1 of every 6 patients treated survive and can be discharged. There is evidence that mortality and the sequels that cause the cardiorespiratory arrests can be decreased if delays in health care response are lessened, with the optimization of the "Hospital Survival Chain". That is, with strategies aimed at: a) early identification and treatment of situations susceptible of precipitating cardiac arrest; b) early detection of Cardiorespiratory Arrest; c) undelayed application of basic CPR; d) early defibrillation; e) initiation of advanced CPR within a few minutes, and f) assisted transfer and admission in Intensive Care Unit. Early defibrillation is the "key to survival". Rhythm disorders are the most frequent precipitating cause of cardiac arrest, although ventricular fibrillation is only documented in one of every four hospital cardiac arrests. In this situation, each minute of delay in performing the defibrillation decreases survival possibilities by 7%-10%. In recent years, mechanisms to improve response to cardiac arrests have been introduced in the hospitals. In spite of the distance traveled, the effort cannot be considered to be sufficient. The fact that our hospitals would have problems to become accredited if the standards contemplated by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) were applied to them serves as an example. The CPR National Plan of the Spanish Society of Intensive, Critical and Coronary Unit Medicine (SEMICYUC), in collaboration with the Spanish Society of Intensive Nursing and Coronary Units (SEEIUC) has elaborated these recommendations in order to contribute towards decreasing mortality, sequels and costs arising from hospital heart arrests. In them, the guidelines made by the International Scientific Societies, specifically by the International Liaison Committee on Resuscitation (ILCOR), is collected. This practically groups all the organizations dedicated to worldwide resuscitation, including the European Resuscitation Council (ERC), which is the organization that adapts these recommendations to our setting and they are the ones on which the National Plan of CPR of the SEMICYUC are based. Furthermore, the line marked in some recent recommendations by the Resuscitation Council of the United Kingdom has been followed in its elaboration