Is minimising waste volume for drawing blood samples in critically ill patients feasible?

INTRODUCTION: Drawing blood samples through a central venous catheter (CVC) is a customary practice in Intensive Care Units (ICUs). It is indicated to discard a volume of waste blood to avoid interference in the results. AIM: To determine whether a lower discard volume for obtaining blood samples from temporary CVCs placed into the internal jugular, femoral or subclavian vein offers valid results. METHOD: A quasi-experimental prospective cross-sectional study for which sixty-five patients of over 18 years of age in ICUs, who had been fitted with a triple lumen central venous catheter, were recruited over a period of eight months. Two consecutive blood samples were extracted with tubes for biochemistry, coagulation and hemogram from each patient from the distal lumen. The first sample was obtained with a discarded waste of 1.5 ml from a total extracted volume of 10.2 ml, similar to the usual waste in our ambit (10 ml). Subsequently the second sample was obtained. The paired t-test was used to analyse the data. The Bland-Altman plot and intraclass correlation coefficient (ICC) were used to measure the agreement between methods. The reference change value (RCV) was established as the admissible limit of variation between the pairs of samples. RESULTS: A total of 65 sample pairs were drawn (intervention-control). The paired t-test found statistically significant differences with a significance level of α = .05 for chlorine (-.536; .012); prothrombin time (-.092; .019) and prothrombin activity (.284; 1.375).The ICC was greater than .9 in all the variables and the limit determined for the RCV was not surpassed by any value. CONCLUSIONS: The results show the reliability of the blood samples drawn with a discard volume of 1.5 ml.

Minimizar el volumen de descarte para la extracción de muestras sanguíneas en los pacientes críticos: ¿es factible? / Is minimising waste volume for drawing blood samples in critically ill patients feasible?

Introducción: La extracción de muestras sanguíneas a través de un catéter venoso central es una práctica habitual en las unidades de cuidados intensivos. Está indicado desechar un volumen de sangre, denominado volumen de descarte, con la finalidad de evitar que los resultados puedan verse alterados. Objetivo: Determinar si un menor volumen de descarte para la obtención de analíticas procedentes de catéter venoso central temporales alojados en la vena yugular interna, femoral o subclavia ofrece resultados válidos. Método: Estudio cuasiexperimental, prospectivo, transversal donde se seleccionaron 65 pacientes críticos mayores de 18 años portadores de catéter venoso central temporal de 3 luces durante un período de 8 meses. Para cada paciente se extrajeron 2 analíticas consecutivas de la luz distal con los valores de hemograma, bioquímica y coagulación comúnmente analizados en el paciente crítico. Se obtuvieron 2 muestras consecutivas: la primera, con un descarte de 1,5ml y un volumen extraído total de 10,2ml, similar al desecho habitual en nuestro medio (10 ml). Seguidamente se obtuvo la segunda muestra. Para el análisis de datos se utilizó la prueba t pareada; para medir la concordancia entre métodos, la representación de Bland-Altman y el coeficiente de correlación intraclase. Se estableció el valor de referencia del cambio como límite admisible de variación entre los pares de muestras. Resultados: Se extrajeron un total de 65 pares de muestras (intervención-control). El contraste de medias encontró diferencias estadísticamente significativas con α=0,05 para cloro (−0,536; 0,012), tiempo de protrombina (−0,092; 0,019) y actividad de protrombina (0,284; 1,375). El coeficiente de correlación intraclase resultó mayor de 0,9 en todas las variables y el valor de referencia del cambio no fue superado por ningún valor. Conclusiones: Los resultados muestran la validez de los análisis de las muestras de sangre extraídas con un volumen de descarte de 1,5ml.(AU)

Introduction: Drawing blood samples through a central venous catheter is a customary practice in intensive care units. It is indicated to discard a volume of waste blood to avoid interference in the results. Aim: To determine whether a lower discard volume for obtaining blood samples from temporary central venous catheters placed into the internal jugular, femoral or subclavian vein offers valid results. Method: A quasi-experimental prospective cross-sectional study for which 65 patients of over 18 years of age in intensive care units, who had been fitted with a triple lumen central venous catheter, were recruited over a period of 8 months. Two consecutive blood samples were extracted with tubes for biochemistry, coagulation and haemogram from each patient from the distal lumen. The first sample was obtained with a discarded waste of 1.5ml from a total extracted volume of 10.2ml, similar to the usual waste in our ambit (10ml). Subsequently the second sample was obtained. The paired t-test was used to analyse the data. The Bland-Altman plot and intraclass correlation coefficient were used to measure the agreement between methods. The reference change value was established as the admissible limit of variation between the pairs of samples. Results: A total of 65 sample pairs were drawn (intervention-control). The paired t-test found statistically significant differences with a significance level of α=0.05 for chlorine (−0.536; 0.012); prothrombin time (−0.092; 0.019) and prothrombin activity (0.284; 1.375). The intraclass correlation coefficient was greater than 0.9 in all the variables and the limit determined for the reference change value was not surpassed by any value. Conclusions: The results show the reliability of the blood samples drawn with a discard volume of 1.5ml.(AU)

Avances en Uro-Oncología «OncoUrology Forum Special Edition»: lo mejor del 2020 / Advances in Urologic Oncology “OncoUrology Forum Special Edition”: The best of 2020

Contexto y objetivo: Conocer las últimas evidencias sobre Urología oncológica de tumores de próstata, riñón y vejiga, analizando su impacto en la práctica clínica diaria, además de los esquemas futuros a medio y largo plazo.Materiales y métodos: Se revisan los resúmenes sobre Uro-Oncología presentados en los Congresos del año 2020 (EUA, AUA, ASCO, ESMO y ASTRO), las publicaciones de mayor impacto y especialmente las nuevas líneas de desarrollo y avance en Uro-Oncología valoradas por el comité de OncoForum.Resultados: El uso de los radioligandos de antígeno de membrana específico de próstata en el diagnóstico de cáncer de próstata puede tener gran cabida y utilidad en los próximos años gracias a su mejor sensibilidad y especificidad. La caracterización genética del tumor es importante tanto a nivel germinal como somático, dado que las mutaciones en BRCA2 son especialmente importantes por su significado en riesgo. El diseño de estudio más conveniente a nivel de cáncer genitourinario es el ensayo controlado aleatorizado múltiple de cohortes. La aplicación del big data traerá mejoras en procesos, ahorros en costes sanitarios y una potenciación de los estudios en vida real gracias a la facilidad de comparación, gestión y almacenamiento de datos.Conclusiones: El uso de las nuevas técnicas diagnósticas con ligandos de antígeno de membrana específico de próstata aportará una modalidad diagnóstica más completa y el aumento de los estudios del perfil genético del tumor y la calidad de los estudios realizados. La aplicación práctica de la inteligencia artificial mejorará el tratamiento del cáncer genitourinario. (AU)

Objective: To provide latest findings of Urologic Oncology on prostate, kidney, and bladder cancer, and analyze its impact on clinical practice as well as future schemes in the medium- and long-term.Methods:This document reviews the abstracts on Uro-Oncology presented at the 2020 Congresses (EUA, AUA, ASCO, ESMO and ASTRO), the publications with the highest impact and especially the new lines of development and progress in Uro-Oncology evaluated by the OncoForum committee.Results: The use of prostate-specific membrane antigen (PSMA) radioligands in the diagnosis of prostate cancer may have great potential and utility in the coming years due to their improved sensitivity and specificity. The genetic characterization of the tumor is important at both, germline and somatic levels, due to the significant role of BRCA2 mutations regarding risk. The cohort multiple randomised controlled trial is the most suitable study design at the genitourinary cancer level. The application of big data will lead to process improvements, savings in healthcare costs, and an empowerment of real-life studies through ease of data comparison, management, and storage.Conclusions:The use of new diagnostic techniques with PSMA ligands will provide a more comprehensive diagnostic modality, increase the number of studies about tumor genetic profiling, and enhance their quality. The practical application of artificial intelligence will improve the treatment genitourinary cancer. (AU)

Advances in urologic oncology "OncoUrology Forum Special Edition": The best of 2020.

OBJECTIVE: To provide latest findings of Urologic Oncology on prostate, kidney, and bladder cancer, and analyze its impact on clinical practice as well as future schemes in the medium- and long-term. METHODS: This document reviews the abstracts on Uro-Oncology presented at the 2020 Congresses (EUA, AUA, ASCO, ESMO and ASTRO), the publications with the highest impact and especially the new lines of development and progress in Uro-Oncology evaluated by the OncoForum committee. RESULTS: The use of prostate-specific membrane antigen (PSMA) radioligands in the diagnosis of prostate cancer may have great potential and utility in the coming years due to their improved sensitivity and specificity. The genetic characterization of the tumor is important at both, germline and somatic levels, due to the significant role of BRCA2 mutations regarding risk. The cohort multiple randomised controlled trial is the most suitable study design at the genitourinary cancer level. The application of big data will lead to process improvements, savings in healthcare costs, and an empowerment of real-life studies through ease of data comparison, management, and storage. CONCLUSIONS: The use of new diagnostic techniques with PSMA ligands will provide a more comprehensive diagnostic modality, increase the number of studies about tumor genetic profiling, and enhance their quality. The practical application of artificial intelligence will improve the treatment genitourinary cancer.

Quantifying traffic, biomass burning and secondary source contributions to atmospheric particle number concentrations at urban and suburban sites.

In this study, we propose a new approach to determine the contributions of primary vehicle exhaust (N1ff), primary biomass burning (N1bb) and secondary (N2) particles to mode segregated particle number concentrations. We used simultaneous measurements of aerosol size distribution in the 12-600 nm size range and black carbon (BC) concentration obtained during winter period at urban and suburban sites influenced by biomass burning (BB) emissions. As expected, larger aerosol number concentrations in the 12-25 and 25-100 nm size ranges are observed at the urban site compared to the suburban site. However, similar concentrations of BC are observed at both sites due to the larger contribution of BB particles to the observed BC at suburban (34%) in comparison to urban site (23%). Due to this influence of BB emissions in our study area, the application of the Rodríguez and Cuevas (2007) method, which was developed for areas mainly influenced by traffic emissions, leads to an overestimation of the primary vehicle exhaust particles concentrations by 18% and 26% in urban and suburban sites, respectively, as compared to our new proposed approach. The results show that (1) N2 is the main contributor in all size ranges at both sites, (2) N1ff is the main contributor to primary particles (>70%) in all size ranges at both sites and (3) N1bb contributes significantly to the primary particles in the 25-100 and 100-600 nm size ranges at the suburban (24% and 28%, respectively) and urban (13% and 20%, respectively) sites. At urban site, the N1ff contribution shows a slight increase with the increase of total particle concentration, reaching a contribution of up to 65% at high ambient aerosol concentrations. New particle formation events are an important aerosol source during summer noon hours but, on average, these events do not implicate a considerable contribution to urban particles.

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care.

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain. PURPOSE: To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures. METHODS: A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated. RESULTS: Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC. CONCLUSIONS: The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Impact of primary NO2 emissions at different urban sites exceeding the European NO2 standard limit.

A large part of the European population is still exposed to ambient nitrogen dioxide (NO2) levels exceeding the European Union (EU) air quality standards, being a key challenge to reduce NO2 concentrations across many European urban areas, particularly close to roads. In this work, a trend analysis of pollutants involved in NO2 processes was done for the period 2003-2014 in traffic sites from three Spanish cities (Barcelona, Madrid and Granada) that still exceed the European NO2 air quality standard limits. We also estimated the contributions of primary NO2 emissions and photo-chemically formed NO2 to the observed ambient NO2 concentrations in order to explore their possible role in the observed NO2 concentration trends. The NOx and NO concentrations at these traffic sites showed significant decreasing trends during the period 2003-2014, especially at Barcelona (BARTR) and Madrid (MADTR) traffic stations. The NO2 concentrations showed statistically significant downward trends at BARTR and MADTR and remained unchanged at Granada traffic station (GRATR) during the study period. Despite the significant decrease in NO2 concentrations in BCNTR and MADTR during the analysed period, the NO2 concentrations observed over these sites still above the annual NO2 standard limit of 40 µg m-3 and, therefore, more efficient measures are still needed. Primary NO2 emissions significantly influence NO2 concentrations at the three analysed sites. However, as no drastic changes are expected in the after-exhaust treatment technology that can reduce primary NO2 emissions to zero in the near future, only a substantial reduction in NOx emissions will help to comply with the NO2 European air quality standards. Reduction of 78%, 56% and 16% on NOx emissions in Barcelona, Madrid and Granada were estimated to be necessary to comply with the NO2 annual limit of 40 µg m-3.

Spatial and temporal variability of carbonaceous aerosols: Assessing the impact of biomass burning in the urban environment.

Biomass burning (BB) is a significant source of atmospheric particles in many parts of the world. Whereas many studies have demonstrated the importance of BB emissions in central and northern Europe, especially in rural areas, its impact in urban air quality of southern European countries has been sparsely investigated. In this study, highly time resolved multi-wavelength absorption coefficients together with levoglucosan (BB tracer) mass concentrations were combined to apportion carbonaceous aerosol sources. The Aethalometer model takes advantage of the different spectral behavior of BB and fossil fuel (FF) combustion aerosols. The model was found to be more sensitive to the assumed value of the aerosol Ångström exponent (AAE) for FF (AAEff) than to the AAE for BB (AAEbb). As result of various sensitivity tests the model was optimized with AAEff=1.1 and AAEbb=2. The Aethalometer model and levoglucosan tracer estimates were in good agreement. The Aethalometer model was further applied to data from three sites in Granada urban area to evaluate the spatial variation of CMff and CMbb (carbonaceous matter from FF or BB origin, respectively) concentrations within the city. The results showed that CMbb was lower in the city centre while it has an unexpected profound impact on the CM levels measured in the suburbs (about 40%). Analysis of BB tracers with respect to wind speed suggested that BB was dominated by sources outside the city, to the west in a rural area. Distinguishing whether it corresponds to agricultural waste burning or with biomass burning for domestic heating was not possible. This study also shows that although traffic restrictions measures contribute to reduce carbonaceous concentrations, the extent of the reduction is very local. Other sources such as BB, which can contribute to CM as much as traffic emissions, should be targeted to reduce air pollution.

Colorimetric analysis of outdoor illumination across varieties of atmospheric conditions.

Solar illumination at ground level is subject to a good deal of change in spectral and colorimetric properties. With an aim of understanding the influence of atmospheric components and phases of daylight on colorimetric specifications of downward radiation, more than 5,600,000 spectral irradiance functions of daylight, sunlight, and skylight were simulated by the radiative transfer code, SBDART [Bull. Am. Meteorol. Soc.79, 2101 (1998)], under the atmospheric conditions of clear sky without aerosol particles, clear sky with aerosol particles, and overcast sky. The interquartile range of the correlated color temperatures (CCT) for daylight indicated values from 5712 to 7757 K among the three atmospheric conditions. A minimum CCT of ∼3600 K was found for daylight when aerosol particles are present in the atmosphere. Our analysis indicated that hemispheric daylight with CCT less than 3600 K may be observed in rare conditions in which the level of aerosol is high in the atmosphere. In an atmosphere with aerosol particles, we also found that the chromaticity of daylight may shift along the green-purple direction of the Planckian locus, with a magnitude depending on the spectral extinction by aerosol particles and the amount of water vapor in the atmosphere. The data analysis showed that an extremely high value of CCT, in an atmosphere without aerosol particles, for daylight and skylight at low sun, is mainly due to the effect of Chappuis absorption band of ozone at ∼600 nm. In this paper, we compare our data with well-known observations from previous research, including the ones used by the CIE to define natural daylight illuminants.

A long-term study of new particle formation in a coastal environment: meteorology, gas phase and solar radiation implications.

New particle formation (NPF) was investigated at a coastal background site in Southwest Spain over a four-year period using a Scanning Particle Mobility Sizer (SMPS). The goals of the study were to characterise the NPF and to investigate their relationship to meteorology, gas phase (O3, SO2, CO and NO2) and solar radiation (UVA, UVB and global). A methodology for identifying and classifying the NPF was implemented using the wind direction and modal concentrations as inputs. NPF events showed a frequency of 24% of the total days analysed. The mean duration was 9.2±4.2 h. Contrary to previous studies conducted in other locations, the NPF frequency reached its maximum during cold seasons for approximately 30% of the days. The lowest frequency took place in July with 10%, and the seasonal wind pattern was found to be the most important parameter influencing the NPF frequency. The mean formation rate was 2.2±1.7 cm(-3) s(-1), with a maximum in the spring and early autumn and a minimum during the summer and winter. The mean growth rate was 3.8±2.4 nm h(-1) with higher values occurring from spring to autumn. The mean and seasonal formation and growth rates are in agreement with previous observations from continental sites in the Northern Hemisphere. NPF classification of different classes was conducted to explore the effect of synoptic and regional-scale patterns on NPF and growth. The results show that under a breeze regime, the temperature indirectly affects NPF events. Higher temperatures increase the strength of the breeze recirculation, favouring gas accumulation and subsequent NPF appearance. Additionally, the role of high relative humidity in inhibiting the NPF was evinced during synoptic scenarios. The remaining meteorological variables (RH), trace gases (CO and NO), solar radiation, PM10 and condensation sink, showed a moderate or high connection with both formation and growth rates.

[Melanoma, altitude, and UV-B radiation]. / Melanoma, altitud y radiación UVB.

BACKGROUND AND OBJECTIVES: UV radiation is the main modifiable risk factor for the development of cutaneous melanoma. Many people in the Spanish province of Granada live at high altitudes and, therefore, receive high doses of UV-B radiation. The aims of this study were to assess the possible association between melanoma and altitude and to measure the daily erythemal dose at different altitudes. MATERIAL AND METHODS: An epidemiological study was carried out between 1982 and 2007 to assess the relationship between altitude, daily erythemal dose, and the prevalence of melanoma. We calculated the prevalence of melanoma in patients with a clinical and histological diagnosis of melanoma at Hospital Clínico Universitario San Cecilio in Granada, Spain. All individuals were required to be residents of the province of Granada in order to be included in the study. The prevalence of melanoma was calculated for altitude intervals of 100 m. Daily erythemal dose was estimated using measures of UV-B radiation obtained with pyranometers at altitudes of 0, 680, 1200, and 3398 m above sea level during the Evaluation of the Effects of Elevation and Aerosols on UV Radiation (VELETA) 2002 field campaign. RESULTS: The highest prevalence of melanoma was found between 1400 and 1499 m above sea level (the interval at which the highest settlements are found), with a rate of 2.36 cases per 1000 inhabitants (95% confidence interval, 0.64-6.03). Above 700 m, the daily erythemal dose increased exponentially with increasing altitude. CONCLUSIONS: We observed a tendency toward increased prevalence of melanoma at higher altitude, with higher prevalences observed beyond 700 m above sea level.

Using a trichromatic CCD camera for spectral skylight estimation.

In a previous work [J. Opt. Soc. Am. A 24, 942-956 (2007)] we showed how to design an optimum multispectral system aimed at spectral recovery of skylight. Since high-resolution multispectral images of skylight could be interesting for many scientific disciplines, here we also propose a nonoptimum but much cheaper and faster approach to achieve this goal by using a trichromatic RGB charge-coupled device (CCD) digital camera. The camera is attached to a fish-eye lens, hence permitting us to obtain a spectrum of every point of the skydome corresponding to each pixel of the image. In this work we show how to apply multispectral techniques to the sensors' responses of a common trichromatic camera in order to obtain skylight spectra from them. This spectral information is accurate enough to estimate experimental values of some climate parameters or to be used in algorithms for automatic cloud detection, among many other possible scientific applications.

[A retrospective study of the effectiveness of lamotrigine in monotherapy for the treatment of epileptic seizures. The ERELMO study]. / Estudio retrospectivo de la efectividad de la lamotrigina en monoterapia para el tratamiento de crisis epilépticas. Estudio ERELMO.

INTRODUCTION: The efficacy and tolerability of lamotrigine (LTG) in monotherapy and in combination therapy have been demonstrated in clinical trials. The aim of the ERELMO study was to retrospectively evaluate the effectiveness and safety of LTG, as monotherapy in the control of epileptic seizures in routine clinical practice in Spain. PATIENTS AND METHODS: 446 clinical records were selected of patients with LTG treatment in the twelve months previously to the beginning of the study. The main endpoints retrospectively analyzed were effectiveness (percentage of patients with 50% or greater reduction in seizure frequency, improvement in seizure control, percentage of patients remaining-seizure free at 2, 6 and 12 months of LTG monotherapy), and safety (adverse event profile reported and treatment withdrawal). RESULTS: The mean age was 41 years old, 57.8% were women. LTG monotherapy treatment (mean maintenance dose was 217.2 mg/day) reduced mean seizure frequency as compared with the basal condition at different study time points (2, 6, 12 months; p < 0.0001). At the end of the study 77% of the patients were seizure free. Loss of treatment effectiveness was shown in 8.5% of patients. Adverse reactions were reported by 15% of patients, the most frequent being insomnia, somnolence, headache and rash. At the end of the study, 88.8% patients were still receiving LTG monotherapy. CONCLUSIONS: The present study supports the use of LTG monotherapy due to its effectiveness and good tolerability to promote treatment compliance in usual clinical conditions in patients with epilepsy.

Development of a sky imager for cloud cover assessment.

Based on a CCD camera, we have developed an in-house sky imager system for the purpose of cloud cover estimation and characterization. The system captures a multispectral image every 5 min, and the analysis is done with a method based on an optimized neural network classification procedure and a genetic algorithm. The method discriminates between clear sky and two cloud classes: opaque and thin clouds. It also divides the image into sectors and finds the percentage of clouds in those different regions. We have validated the classification algorithm on two levels: image level, using the cloud observations included in the METAR register performed at the closest meteorological station, and pixel level, determining whether the final classification is correct.

[The economic impact of epilepsy]. / Impacto económico de la epilepsia.

AIMS: In this study we review the economic impact involved in suffering from this disease in an attempt to determine how it affects both the individual and society, and the potential benefits deriving from its prevention and treatment. DEVELOPMENT: The World Health Organisation and the World Bank have pointed out that 90% of the costs generated by epilepsy are produced in developing countries. Yet in most developed countries the economic impact of the disease remains partially hidden for patients by the existence of publicly funded health service. As regards spending on pharmaceutical products in Spain, the subgroup made up of the antiepileptic drugs accounted for 1.36% of the total spending throughout the year 2001. Nevertheless, the main economic consequence for most patients is the limitation they suffer in their occupational activities, which is inversely proportional to the degree of control over their seizures and considerably higher than in the general population. Moreover, in epilepsy we must not forget the costs linked to its numerous psychological and social consequences. CONCLUSIONS: As happens in other areas of health care, the way epilepsy is attended depends to a large extent on economic factors. Further studies are therefore needed to provide us with a better understanding of the role played by economics in the field of health care.

Alteraciones del equilibrio hidroelectrolítico y ácido-base en la peritonitis generalizada / Alterations in hydroelectrolytic and acid-base equilibrium in generalized peritonitis

La peritonitis secundaria generalizada es una sepsis grave, que se produce como consecuencia de un desequilibrio entre la reacción proinflamatoria sistémica (SIRS) y la antiinflamatoria compensatoria (CARS), que ocasiona un síndrome de disfunción multiorgánica (MODS).El MODS se caracteriza por dos hechos fisiopatológicos esenciales: aumento de la permeabilidad de todas las barreras del organismo y trastornos de la microcirculación con la subsiguiente hipoperfusión textural. El íleo paralítico constituye un hecho trascendental en la fisiopatología de la peritonitis, pues la falta de reabsorción, unida a la hipersecreción de la mucosa y al aumento de permeabilidad de la pared intestinal, propicia un importante secuestro de líquidos en el llamado tercer espacio. Se produce así, además de un profundo trastorno hidroelectrolítico, una hipovolemia grave. La acidosis metabólica que el íleo paralítico origina se potencia por la aparición precoz de un síndrome de insuficiencia respiratoria (ARDS).El tratamiento para ser eficaz ha de conseguir la erradicación quirúrgica total de los focos infecciosos, pues es la única manera de romper el círculo vicioso de la sepsis peritoneal. La fluidoterapia, encaminada a restituir la volemia y el equilibrio hidroelectrolítico y ácido-base, es fundamental, así como el precoz tratamiento del íleo y del ARDS (AU)