Prevalencia y enfoque terapéutico del dolor en el servicio de urgencias de un hospital universitario / Prevalence and therapeutic management of pain in the emergency department of a university hospital

Objetivo: conocer la prevalencia de dolor y su enfoque terapéutico en un servicio de urgencias. Material y métodos: estudio transversal llevado a cabo en el Servicio de Urgencias de un hospital universitario durante 7 días consecutivos. El médico de triaje interrogó sobre la presencia de dolor a los pacientes mayores de 15 años que acudían a urgencias. Se excluyeron los pacientes atendidos en el Servicio de Psiquiatría, Obstetricia-Ginecología y aquellos cuya gravedad no permitía la valoración del dolor en el triaje. Se revisó posteriormente el tratamiento analgésico previo a la visita, la evaluación del dolor, el tratamiento analgésico aplicado durante su estancia en urgencias y el tratamiento pautado al alta. Resultados: se analizaron 668 de los 2.287 pacientes que acudieron a urgencias durante el periodo del estudio. Presentaron dolor 501 pacientes (75 %), de los que 45 ingresaron y 456 fueron dados de alta a domicilio (240 pacientes procedentes de nivel 1 y 216 de nivel 2). El 24,5 % de los 501 pacientes que manifestaron tener dolor realizaba tratamiento analgésico previo. De los 216 pacientes atendidos en el nivel 2, el 41,7 % recibió tratamiento analgésico durante su estancia [paracetamol (80,2 %), antiinflamatorios no esteroideos (AINE) (50 %), coanalgésicos (1 %), opioides débiles (20,8 %), opioides fuertes (3,1 %)]. El 32,7 % de los 196 pacientes sin registro de evaluación del dolor recibió tratamiento analgésico a demanda. En un 69,4 % de los 456 pacientes que no precisaron ingreso, al alta se pautó analgesia o se modificó el tratamiento analgésico previo [paracetamol (55 %), AINE (67 %), co-analgésicos (10 %), opioides débiles (10 %), opioides fuertes (1,1 %)]. Conclusiones: se evidencia una elevada prevalencia de dolor (75 %) en los pacientes que acuden al servicio de urgencias. El 41,7 % de los pacientes que presentaban dolor recibió tratamiento analgésico durante su estancia y en el 69,4 % de los pacientes que no precisaron ingreso se pautó analgesia al alta. Destaca la baja prescripción de opioides (AU)

Aim: To know the prevalence of pain and the therapeutic approach in an emergency department (ED). Material and methods: Cross-sectional study in the ED of a university hospital during 7 consecutive days was performed. The presence of pain was asked by a physician to patients older than 15 years admitted at ED. Patients admitted at Psychiatry, Obstetrics-Gynecology Emergency Department and those whose serious condition would not allow pain assessment in triage were excluded. The previous analgesic treatment, pain assessment, analgesic treatment in the ED and also scheduled treatment at discharge were later reviewed. Results: Six hundred and sixty-eight from 2,287 patients who were admitted at ED were analyzed. Five hundred and one patients reported pain (75 %), of which 45 were admitted and 456 were discharged at home (240 patients in level 1, 216 at level 2). The 24.5 % of the 501 patients who reported pain at admission were previously treated with analgesics. The 41.7 % of the 216 patients treated at level 2 received analgesic treatment during their stay [paracetamol (80.2 %), nonsteroidal antiinflammatory drugs (NSAIDs) (50.0 %), co-analgesics (1.0 %), weak opioids (20.8 %), strong opioids (3.1 %)]. The 32.7 % of the 196 patients without documented pain assessment received analgesic treatment as required. In 69.4 % of the 456 patients who did not require hospitalization, analgesic treatment was prescribed or modified at discharge [paracetamol (55 %), nonsteroidal anti-inflammatory drugs (NSAIDs) (67 %), co-analgesics (10 %), weak opioids (10 %), strong opioids (1.1 %)]. Conclusions: A high prevalence of pain (75 %) was found in patients admitted at ED. The 41.7 % received analgesic treatment during their stay and in 69.4 % of patients analgesia was prescribed at discharge. Low opioid prescription was detected (AU)

Implementación de un “Código Sepsis Grave” en un servicio de urgencias / Emergency department implementation of a severe sepsis code

Objetivo: Analizar el grado de cumplimiento y de consecución de los objetivos hemodinámicos de un Código de Sepsis Grave (CSG).Método: Estudio prospectivo-observacional (octubre 2006-marzo 2007) de los pacientes que cumplían los tres criterios siguientes: 1. Sospecha de infección;2. Tª <36ºC o >38 ºC o FC >90 x’ o FR >20 x’ o alteración del nivel de conciencia.3. Presión arterial sistólica (PAS) <90 mmHg o presión arterial media(PAM) < 70 mmHg o disminución de la presión arterial >40 mmHg en hipertensos. Se recogieron variables clínicas, y el grado de aplicación medido en las primeras 6 horas, de consecución de objetivos hemodinámicos y mortalidad intrahospitalaria. Resultados: La edad media fue de 58,4 ± 20 años y el 70,7% eran hombres. El foco infeccioso más frecuente fue el respiratorio (50%). El grado de activación fue del 64,5%.La mortalidad intrahospitalaria fue del 17,5%. El grado de consecución de objetivos hemodinámicos fue: PAM 65 mmHg en el 77,5%, diuresis 0,5 mL/Kg/h en el 82,5%,presión venosa central (PVC) 8-12 mmHg en el 45,4% y saturación venosa central de oxígeno (SvcO2) 70% en 15,6%. El grado de aplicación de medidas fue: hemocultivos previos a antibiótico: 90%, administración de antibiótico antes de 3 horas: 95,7%, medición de lactato: 97,5%, resucitación con volumen suficiente: 80%, administración de noradrenalina: 80%, medición de PVC: 72,7% y medición de SvcO2: 31,2%.Conclusiones: La implantación de un CSG ha permitido homogeneizar el manejo de la sepsis grave/shock séptico, sensibilizar al personal sanitario para su detección y tratamiento precoz y detectar aspectos susceptibles de mejora (AU)

Objective: To analyze the degree of compliance with a severe sepsis code and the achievement of hemodynamic goals under that code. Methods: Prospective observational study (October 2006 through March 2007) of patients meeting the following sets of inclusion criteria: 1) suspicion of infection; 2) temperature < 36ºC or >38ºC, or heart rate > 90 beats/min or respiratory rate > 20 breaths/min, or diminished level of consciousness; and 3) systolic blood pressure < 90 mm Hg, or mean arterial pressure < 70 mm Hg, or a decrease in blood pressure > 40 mm Hg in hypertensive individuals. We recorded clinical variables, degree of compliance with measures specified in the code in the first 6 hours, success in reaching hemodynamic goals, and hospital mortality. Results: The mean (SD) age was 58.4 (20) years and 70.7% were men. The respiratory tract was the most frequent focus of infection (in 50% of the cases). The code was implemented in 64.5% of the cases. In-hospital mortality was 17.5%.Regarding achievement of hemodynamic goals, a mean arterial pressure 65 mm Hg was reached in 77.5%, dieresis 0.5 mL/kg/h was observed in 82.5%, and a central venous pressure of 8 mm Hg to 12 mm Hg was reached in 45.4%and a central venous oxygen saturation (SvcO2) of 70% in 15.6%. The level of compliance with each stipulated measure was as follows: blood cultures before starting an antibiotic, 90%; administration of an antibiotic within 3 hours,95.7%; measurement of lactate level, 97.5%; resuscitation with adequate volume, 80%; administration of noradrenalin,80%; and measurement of central venous pressure and SvcO2, in 72.7% and 31.2%, respectively. Conclusions: Implementing a severe sepsis code facilitated the achievement of consistent management of this condition. Emergency personnel were alert to detecting sepsis and treating it early, and they became aware of aspects of care that could be improved (AU)

[Mitral endocarditis secondary to Streptococcus mitis bacteremic pneumonia]. / Endocarditis mitral secundaria a neumonía bacteriémica por Streptococcus mitis.

Streptococcus viridans usually are an etiologic agent in odontogenic infection and endocarditis and only in some cases have been acknowledged as a respiratory pathogens. We present two cases of Streptococcus mitis bacteremic pneumonia with secondary mitral endocarditis in two patients that were been admitted by a respiratory infection (pneumonia), and later diagnosticated of mitral endocarditis. We dismiss the fisiopathogenic possibility of pneumonia with secondary pulmonary septic embolisms. With this description we help to prove the S. mitis respiratory system pathogenicity and show the known risk of endocarditis in any case of Streptococcus viridans bacteremic infection.

[Fiber optics bronchoscopy yield and predictive clinical, analytical, and radiologic factors in the etiologic diagnosis of pulmonary pathology in patients with HIV infection]. / Rendimiento de la fibrobroncoscopia y factores predictivos clínicos, analíticos y radiológicos en el diagnóstico etiológico de la patología pulmonar en pacientes con infección por VIH.

UNLABELLED: The aim of this study was to assess the diagnostic performance of fibrobronchoscopy (FBS) in the pulmonary pathology of HIV-positive patients, in order to study the effect of several factors on such performance and to evaluate if these factors could guide the etiologic diagnosis. A retrospective study of 49 FBS with bronchoalveolar lavage (BAL) was performed in 44 HIV-positive patients. The diagnostic performance of FBS with BAL was 71.4%, with no significant modifications caused by previous prophylactic or empirical therapies, time of clinical evolution, radiological pattern, presence of hypoxemia or CD4 count. On the contrary, a high LDH was associated to a higher diagnostic performance. DIAGNOSIS: Pneumonia by Pneumocystis carinii (36.7%), M. tuberculosis (28.6%) and bacterial pneumonias (16.3%). The presence of biliary adenopathies, evolution longer than 1 week and pO2 > 80 mm Hg had a high sensitivity of 28.5% and a specificity of 97% for the diagnosis of tuberculosis, with a positive predictive value of 80% and a negative predictive value of 77.7%.