Situación de los cuidados intensivos en España / Intensive care in Spain

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Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida / Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome

Presentamos un caso de una paciente de 38 años, que acudió a urgencias por cuadro de insuficiencia respiratoria aguda severa y fue ingresada en la Unidad de Cuidados Críticos con la sospecha diagnóstica inicial de neumonía adquirida en la comunidad producida por gérmenes atípicos, que se complicó con un síndrome de distrés respiratorio agudo. Este pudo ser tratado con ventilación mecánica no invasiva. A las 48h de su ingreso se informó del crecimiento de bacilos gramnegativos en los hemocultivos, identificados posteriormente como Salmonella enteritidis. Esta información, unida a la linfopenia que presentaba la paciente, sugería un estado de inmunodepresión, por lo que se realizaron pruebas serológicas que resultaron positivas para VIH. Fueron instaurados tratamientos antimicrobianos basados en los hallazgos microbiológicos y la evolución clínica de la paciente fue favorable(AU)

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient(AU)

[Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome]. / Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida.

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.

[Resuscitation damage control in the patient with severe trauma]. / Reanimación de control de daños en el paciente adultocon trauma grave.

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.

Resuscitation damage control in the patient with severe trauma

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients(AU)

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[Assessment of neurologic function and complications in a retrospective cohort of patients with acute spinal cord injury due to trauma treated with large-dose methylprednisolone]. / Evaluación de la lesión neurológica y complicaciones médicas en una cohorte histórica de pacientes con lesión medular aguda traumática tras tratamiento con megadosis de metilprednisolona.

BACKGROUND AND OBJECTIVE: Methylprednisolone was used to improve neurologic recovery from spinal cord injury in the National Acute Spinal Cord Injury Studies (NASCIS). Debate over this use led to further research and a 2002 report stating that there was insufficient evidence to support this application as a standard therapy. Our aim was to retrospectively assess this application in a cohort of patients with spinal cord injury. METHODS: Retrospective cohort study of patients admitted to the intensive care unit (ICU) between 1997 and 2007 with a diagnosis of spinal cord injury due to trauma. The patients were grouped according to medical treatment received into a methylprednisolone group and a no-methylprednisolone group. We assessed change in neurologic function on the impairment scale of the American Spinal Injury Association on ICU admission and on discharge. We also recorded medical complications in each group. Cox multiple regression analysis was used to analyze differences between treatments. RESULTS: No significant differences were detected in neurologic outcome on discharge from the ICU (odds ratio [OR], 1.57; 95% confidence interval [CI], 0.69-3.54). The methylprednisolone-treated patients had more medical complications such as hyperglycemia (OR, 5.67; 95% CI, 1.85-17.31) or gastrointestinal bleeding (OR, 19.16; 95% CI, 1.64-223.30) than the patients who did not receive methylprednisolone. CONCLUSIONS: In this retrospective study, methylprednisolone was unrelated to improvement in neurologic outcome after acute spinal cord injury on ICU discharge although the patients treated with this drug were at greater risk of metabolic complications.

Glomerular hyperfiltration and albuminuria in critically ill patients.

Glomerular hyperfiltration and albuminuria are two pathological conditions that could alter renal drug elimination, but they have been rarely studied in a critical care setting. The aims of this descriptive, prospective study performed on 89 critically ill patients are to determine rates of glomerular hyperfiltration (main objective) and albuminuria (secondary objective). On admission, 17.9% of patients presented with glomerular hyperfiltration, climbing to rates as high as 30% during the first week of admission. Seventy-five percent showed albuminuria on admission, with rates remaining high throughout the week of the study. Since glomerular hyperfiltration as well as albuminuria are frequent pathophysiological conditions in critical care patients, the implications that these phenomena may have regarding drug elimination need further evaluation.

Infecciones urinarias en una unidad de reanimación / Urinary tract infections in a postoperative recovery unit

OBJETIVOS: Conocer la frecuencia, etiología, factores deriesgo, y mortalidad relacionados con la infección del tractourinario (ITU) en una Unidad de Reanimación.MATERIAL Y MÉTODOS: Estudio prospectivo de los años1998-2003, ambos inclusive, de todos los pacientes coningreso superior a 48 horas y con seguimiento hasta las 48horas posteriores al alta de una unidad de cuidados críticospolivalentes de 12 camas. Análisis descriptivo, univariantey multivariable con regresión de Cox para los episodiosde ITU nosocomiales.RESULTADOS: La densidad de incidencia de ITU asociadaa sondaje vesical es de 8,4 por 1.000 pacientes-día. Lospatógenos aislados con más frecuencia en los pacientes conbacteriuria son Candida albicans y Escherichia coli. El germenaislado con más frecuencia en las ITU de los pacientestraumáticos es Escherichia coli, mientras que Candidaalbicans predomina en la cohorte de pacientes postquirúrgicos.Tras el análisis multivariable, tres son los factores deriesgo hallados: grado de severidad a la admisión, duraciónde la cateterización y la presencia de diabetes mellitas.El riesgo de mortalidad en pacientes con sondaje urinarioe ITU es de 2,20.CONCLUSIONES: Las ITU tienen consecuencias potencialmentegraves y son responsables de sobremortalidad. Sedesconoce su importancia real y probablemente se lasubestima pese a la publicación de múltiples estudios. Secomprueba que la microbiología de la ITU de las cohortestraumáticas y postquirúrgicas es marcadamente diferenteen nuestra unidad (AU)

OBJETIVE: To analyze the frequency, etiology, riskfactors, and mortality relating to urinary tract infection(UTI) in a postoperative recovery unit.MATERIALS AND METHODS: A prospective study wascarried out from 1998 through 2003 of all patients whostayed longer than 48 hours in a 12-bed critical care unitand who were followed to 48 hours following dischargefrom the unit. A descriptive statistics were compiled andunivariate and multiple variable Cox regression analyseswere performed for episodes of nosocomial UTI.RESULTS: The incidence density for UTI associated withbladder catheterization was 8.4 cases per 1000 patientdays.The pathogens most frequently isolated in patientswith bacteriuria were Candida albicans and Escherichiacoli. The pathogen most frequently isolated in UTI intrauma patients was E coli, whereas C albicans was mostoften found in the postoperative patients. Multivariableanalysis identified 3 risk factors: degree of severity onadmission, duration of catheterization, and presence ofdiabetes mellitus. The mortality risk in patients withbladder catheterization and UTI was 2.20.CONCLUSIONS: UTIs can have serious consequences andare responsible for excess mortality. The real importanceof UTI is unknown and is probably underestimateddespite the publication of many studies. We found that theUTI microbiology findings were markedly different for thetrauma and postoperative cohorts in our department (AU)

[Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit]. / Incidencia de las neumonías nosocomiales precoces y tardías asociadas a ventilación mecánica en una unidad de reanimación- críticos polivalente.

OBJECTIVES: To ascertain the frequency, risk factors, and causes of early- and late-onset ventilator-associated pneumonia (VAP) in a postanesthesia and critical care unit. MATERIAL AND METHODS: A prospective study was carried out between January 1, 1996 and December 31, 2001 of all ventilated patients staying longer than 48 hours in the critical care unit, with follow-up for 48 hours following discharge from the unit. Descriptive statistics were compiled for episodes of early- and late-onset VAP for a period of up to 4 days after intubation; univariate and multiple variable Cox regression analyses were also carried out. RESULTS: A total of 3614 patients were admitted to the unit (study cohort, 652 patients). The mean length of stay in the unit for the study cohort was 13.64 days. The most frequent diagnosis was multiple trauma (50.46%). The incidence density of VAP was 20.31 cases per 1000 patient-days on mechanical ventilation. The pathogens most often isolated in early-onset VAP cases were Staphylococcus aureus and Pseudomonas aeruginosa. In late-onset cases, the pathogens were Pseudomonas species. Early-onset VAP was 2.54 and 2.81 times more frequent in comatose and head-injury patients, respectively. Those rates were significantly different in late-onset cases. CONCLUSIONS: Early-onset VAP was more common in comatose and head-injury patients. The risk of developing late-onset versus early-onset VAP was twice as great for postoperative patients.

Incidencia de las neumonías nosocomiales precoces y tardías asociadas a ventilación mecánica en una unidad de reanimacióncríticos polivalente / Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit

OBJETIVO: Conocer la frecuencia, factores de riesgo y etiología de neumonía nosocomial (NN) asociada a ventilación mecánica (NAVM) precoz y tardía en Unidad de Críticos polivalente (UR). MATERIAL Y MÉTODOS: Estudio prospectivo desde 1/01/1996 al 31/12/2001 de todos los pacientes ventilados con ingreso superior a 48 horas, con seguimiento hasta las 48 horas posteriores al alta de la Unidad. Análisis descriptivo, univariante y multivariable con regresión de Cox para los episodios de NAVM precoz y tardía, con un periodo de corte de 4 días postintubación. RESULTADOS: El total de pacientes ingresados fue de 3.614 pacientes (cohorte de estudio: 652 pacientes). La media de la estancia en la UR para la cohorte fue de 13,64 días. El diagnostico más frecuente (50,46%) fue el paciente politraumatizado. La densidad de incidencia de NAVM fue de 20,31 NN por 1.000 pacientes-día de ventilación mecánica. En la neumonía precoz los patógenos más frecuentemente aislados fueron Staphylococcus aureus y Pseudomonas aeruginosa, en los casos de neumonías tardías resalta el género Pseudomonas. La NAVM precoz fue 2,54 y 2,81 veces más frecuente en pacientes en estados comatosos y en enfermos con traumatismo craneoencefálico de forma respectiva, con diferencias estadísticamente significativas con respecto a los pacientes con NAVM tardía. CONCLUSIONES: La NAVM precoz fue más frecuente en pacientes con estados comatosos y con traumatismo craneoencefálico. La presencia de intervención quirúrgica supuso el doble de riesgo de desarrollar una NAVM tardía en relación a las precoces

OBJECTIVES: To ascertain the frequency, risk factors, and causes of early- and late-onset ventilator-associated pneumonia (VAP) in a postanesthesia and critical care unit. MATERIAL AND METHODS: A prospective study was carried out between January 1, 1996 and December 31, 2001 of all ventilated patients staying longer than 48 hours in the critical care unit, with follow-up for 48 hours following discharge from the unit. Descriptive statistics were compiled for episodes of early- and lateonset VAP for a period of up to 4 days after intubation; univariate and multiple variable Cox regression analyses were also carried out. RESULTS: A total of 3614 patients were admitted to the unit (study cohort, 652 patients). The mean length of stay in the unit for the study cohort was 13.64 days. The most frequent diagnosis was multiple trauma (50.46%). The incidence density of VAP was 20.31 cases per 1000 patientdays on mechanical ventilation. The pathogens most often isolated in early-onset VAP cases were Staphylococcus aureus and Pseudomonas aeruginosa. In late-onset cases, the pathogens were Pseudomonas species. Early-onset VAP was 2.54 and 2.81 times more frequent in comatose and head-injury patients, respectively. Those rates were significantly different in late-onset cases. CONCLUSIONS: Early-onset VAP was more common in comatose and head-injury patients. The risk of developing late-onset versus early-onset VAP was twice as great for postoperative patients

[PiCCO monitoring of 4 critically ill patients]. / Utilización del monitor PiCCO en cuatro pacientes en estado crítico.

The PiCCO physiological monitor (Pulsion Medical Systems, Munich, Germany) was used for hemodynamic diagnosis and monitoring of 4 patients: a polytraumatized female patient with septic shock and ventilator-associated pneumonia; a man with congestive heart failure and cor pulmonale who developed acute heart failure while recovering from anterior resection of the rectum; a man with severe head injury and acute respiratory distress syndrome; and a polytraumatized male patient with a myocardial contusion. All were in a life-threatening situation, either immediately as in the case of the patient with myocardial contusion or eventually as in the patient with septic shock. The PiCCO monitor recorded hemodynamic parameters satisfactorily, facilitating adjustments to optimize treatment. The risks and complications of the usual method of monitoring by Swan-Ganz catheter are well-known. New less invasive monitoring systems designed to record parameters similar to those detected by the Swan-Ganz catheter but with fewer complications and risks have become available. One example, the PiCCO monitor, combines arterial thermodilution with analysis of the pulse waveform, providing a series of hemodynamic parameters useful for managing the critically ill patient.

[Open cholecystectomy under thoracic epidural anesthesia in diffuse interstitial lung disease]. / Colecistectomía abierta bajo anestesia epidural torácica en enfermedades intersticiales difusas del pulmón.

Two patients, aged 73 and 58 years, with diffuse pulmonary fibrosis underwent emergency open cholecystectomies (subcostal approach) under thoracic epidural anesthesia with 0.5% ropivacaine and fentanyl in spontaneous ventilation. Pulmonary fibrosis was due to amiodarone administration in the first patient and of unknowon cause in the second. Both developed arterial hypotension without bradycardia in spite of optimal preloading. Inotropoic support with low doses of norepinephrine was requiered for recovery in both cases with no adverse events after reversion of the sympathetic blocks. Postoperative epidural analgesia was very satisfactory. Thoracic epidural anesthesia is a useful alternative to general anesthesia for subcostal cholecystectomy in patients with diffuse interstitial lung disease in advanced stages.