Los síndromes pericárdicos agudos en la unidad de cuidados intensivos / Acute pericardial syndromes in the intensive care unit

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Utilidad de la resonancia magnética potenciada en difusión en pacientes con lesiones focales por traumatismo craneoencefálico grave / Utility of diffusion-weighted magnetic resonance imaging in severe focal traumatic brain injuries

Objetivo Describir el coeficiente de difusión aparente (CDA) medido mediante resonancia magnética potenciada en difusión (RMD) en una serie de pacientes con traumatismo craneoencefálico (TCE) grave, sus aspectos clínicos y pronósticos y sus posibles implicaciones Diseño Estudio observacional, descriptivo de serie de casos Pacientes e intervenciones Pacientes con TCE grave, ingresados en UCI que no presentan contraindicaciones para traslado y realización de resonancia magnética (RM). Se realizó RM usando un scanner de 1.5 Tesla. Las imágenes potenciadas en difusión se obtuvieron usando una secuencia de pulso eco-planar con las siguientes características: TR 10.000 ms, TE 126,9 ms, valores b 1.000 s/mm2 en las tres direcciones del espacio. Combinando los tres sets de imágenes se obtuvo una imagen isotrópica que constituyó el mapa de los CDA medios. Resultados RMD se realizó en 23 pacientes con TCE grave ingresados en UCI entre 2001 y 2004. Se seleccionaron para su análisis 26 regiones de interés y se recogió el CDA en cada una de ellas. Se observó un incremento en la difusión en las lesiones ocupantes de espacio no evacuadas respecto a otros tipos de lesión y a valores normales. El pronóstico, según la escala de resultados de Glasgow, fue peor en los pacientes con valores de CDA más bajos. Conclusiones Los CDA medios fueron mayores que los valores normales y mayores en las contusiones que en otros tipos de lesión, como expresión de edema extracelular. Los CDA estaban disminuidos en pacientes con mal pronóstico sugiriendo una asociación entre isquemia y pronóstico(AU)

Objective To describe the apparent diffusion coefficient (ADC) in a series of severe traumatic brain injuries, their clinical and outcome features, and possible implications. Design A descriptive, observational case-series study was carried out. Patients and interventions Patients with severe traumatic brain injuries (TBIs) admitted to the ICU were subjected to MRI study using a 1.5 T scanner. Diffusion-weighted images (DWMR) were obtained using the following echo-planar pulse sequence: TR 10000 ms, TE 126.9 ms, with b values 1000 s/mm2 in the three spatial dimensions. Combining the three sets of images, an isotropic image conforming a map of the mean ADCs was obtained. Results DWMR was performed in 23 patients with severe TBI admitted to the ICU between 2001 and 2004. In the MR images we selected 26 regions of interest (ROIs) where ADC was recorded. We observed a clear increase in diffusion in non-treated space-occupying lesions versus other types of injuries and the normal values. A poorer outcome was recorded in patients with lower ADC values. Conclusions Mean ADC in the lesions was greater than the normal values and greater in contusions than in other types of injuries, as an expression of extracellular edema. ADCs were decreased in patients with a poor outcome, suggesting an association between ischemia and the patient prognosis (AU)

[Utility of diffusion-weighted magnetic resonance imaging in severe focal traumatic brain injuries]. / Utilidad de la resonancia magnética potenciada en difusión en pacientes con lesiones focales por traumatismo craneoencefálico grave.

OBJECTIVE: To describe the apparent diffusion coefficient (ADC) in a series of severe traumatic brain injuries, their clinical and outcome features, and possible implications. DESIGN: A descriptive, observational case-series study was carried out. PATIENTS AND INTERVENTIONS: Patients with severe traumatic brain injuries (TBIs) admitted to the ICU were subjected to MRI study using a 1.5 T scanner. Diffusion-weighted images (DWMR) were obtained using the following echo-planar pulse sequence: TR 10000 ms, TE 126.9 ms, with b values 1000 s/mm2 in the three spatial dimensions. Combining the three sets of images, an isotropic image conforming a map of the mean ADCs was obtained. RESULTS: DWMR was performed in 23 patients with severe TBI admitted to the ICU between 2001 and 2004. In the MR images we selected 26 regions of interest (ROIs) where ADC was recorded. We observed a clear increase in diffusion in non-treated space-occupying lesions versus other types of injuries and the normal values. A poorer outcome was recorded in patients with lower ADC values. CONCLUSIONS: Mean ADC in the lesions was greater than the normal values and greater in contusions than in other types of injuries, as an expression of extracellular edema. ADCs were decreased in patients with a poor outcome, suggesting an association between ischemia and the patient prognosis.

Coma y acidosis metabólica: intoxicación por metanol / Coma and metabolic acidosis: methanol poisoning

La intoxicación por metanol es un proceso poco frecuente en la actualidad, a pesar de su uso habitual en la industria, laboratorios y hogar. La vía de intoxicación suele ser la oral y, dada su elevada mortalidad, debe considerarse siempre una intoxicación grave. Se presenta el caso clínico de un paciente joven extranjero sin antecedentes, en coma y con acidosis metabólica grave, que evoluciona a muerte encefálica a pesar de establecer medidas de soporte y tratamiento específico (corrección de acidosis, etanol, diálisis) instaurado empíricamente a las 12 horas del ingreso, confirmándose posteriormente la intoxicación por metanol. En conclusión, debe destacarse la importancia del diagnostico precoz, dado el amplio periodo de latencia, la escasa sintomatología inicial y la alta mortalidad, sospechándose ante un paciente con acidosis metabólica con anión gap aumentado y alteraciones neurológicas, pues el diagnóstico de certeza es su presencia en plasma, técnica no disponible en la mayoría de los hospitales (AU)

Today, the methanol poisoning is an uncommon disease, although it is the regular use in the industry, the laboratories and home products. The more frequent route of intoxication is oral and always it has to considerate that is a severe poisoning. The case report is about a foreign young male without personal history. On first examination he presents coma and severe metabolic acidosis developing encephalic death, despite supportive measures and specific treatment (correction of acidosis, ethanol and dialysis) administered 12 hours after the admission time. Later, the methanol poisoning was confirmed. In conclusion, we want to emphasize the importance of early diagnostic, because this intoxication has a wide latent period, poor initial symptoms and high mortality, and it should be suspected when a patient shows metabolic acidosis with increased gap anion and neurological disorders, since certainly diagnostic is the presence of methanol in blood and this technique is not available in most hospitals (AU)

¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I? / Is the permanent pacemaker implant more efficient in level 1 hospital?

Objetivo Determinar si el implante de marcapasos permanentes (MPP) y cambio de generador resultan más eficientes en hospitales pequeños.DiseñoAnálisis de costeefectividad. Estudio retrospectivo, transversal y observacional de cinco GDR.AmbitoLos datos son procedentes del conjunto mínimo básico de datos (CMBD) nacional del año 2007, facilitado por el Ministerio de Sanidad.PacientesSon el total de los pacientes que requirieron asistencia en algún hospital nacional por 5 GRD: 115, complicación bradiarrítmica durante la fase aguda de un síndrome coronario, insuficiencia cardíaca o shock; 116, trastorno de conducción sintomático aislado; 117, revisión pero sin cambio de batería; 118, aplicación de una nueva, y 549, implantación o revisión pero con complicaciones graves.Variables de interés principalesSe analizaron variables demográficas, clínicas (número de diagnósticos secundarios (NDS), de procedimientos (NP), mortalidad) y de gestión (estancia total y preoperatoria (Epo), forma de acceso y alta, tamaño de hospital), definiendo ineficiente una estancia superior 2 días a la media.Resultados23.154 episodios (5,3% en hospitales<200 camas). El estudio bivariado comparativo entre hospitales pequeños y el resto, no discriminado por GDR, mostró estancia media 7,87±11,01 días vs 8,78±12,95 (p=0,005, IC 95% [0,17; 1,65]) y Epo 3,62±6,14 vs 4,22±6,68 días [p=0,015]), sin mayor comorbilidad, medida como proxy por NDS (5,23±2,88 vs 5,42±3,28 [p=0,055]); y NP como proxy de esfuerzo diagnóstico-terapéutico (3,79±2,50 vs 3,55±2,69 [p=0,002]). 24,1% fueron ineficientes, encontrándose asociación con Epo, NDS, NP y acceso urgente.ConclusionesLa implantación de marcapasos y cambio de generador en hospitales pequeños es más eficiente, con consistencia interna por subgrupos (AU)

Abstract Objective: To determine if permanent pacemaker implants (PPM) interventions and change ofgenerator are more efficient in small hospitals.Design: A cost-effective analysis and retrospective, cross-sectional and observational study ofdiagnostic related groups (DRG).Setting: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year2007 provided by the Health Ministry.Patients: This includes the total number of patients who required treatment in all nationalhospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome,heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but withoutchanging the battery, 118- application of a new one, 549 - implementation or revision butwith serious complications.Principal variables of interest: demographic, clinical (number of secondary diagnoses (NSD)and procedures (NP), mortality) and management (total and preoperative length of stay (LOS),access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on theaverage.Results: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between smallhospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively(3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured byproxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic andtherapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, therebeing an association with preoperative stay, NDS, NP and emergency access.Conclusion: Pacemaker implantation and generator change in small hospitals is more efficient,with internal consistency by subgroups (AU)

Efectos adversos, intercomunicación, gestión del conocimiento y estrategias de cuidados en enfermería intensiva / Adverse effects, intercommunication, management of knowledge and care strategies in intensive nursing

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[Is the permanent pacemaker implant more efficient in level 1 hospital?]. / ¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I?

OBJECTIVE: To determine if permanent pacemaker implants (PPM) interventions and change of generator are more efficient in small hospitals. DESIGN: A cost-effective analysis and retrospective, cross-sectional and observational study of diagnostic related groups (DRG). SETTING: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year 2007 provided by the Health Ministry. PATIENTS: This includes the total number of patients who required treatment in all national hospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome, heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but without changing the battery, 118- application of a new one, 549 - implementation or revision but with serious complications. PRINCIPAL VARIABLES OF INTEREST: demographic, clinical (number of secondary diagnoses (NSD) and procedures (NP), mortality) and management (total and preoperative length of stay (LOS), access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on the average. RESULTS: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between small hospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs 11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively (3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured by proxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic and therapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, there being an association with preoperative stay, NDS, NP and emergency access. CONCLUSION: Pacemaker implantation and generator change in small hospitals is more efficient, with internal consistency by subgroups.

[Prevalence of processes and pathologies in emergency hospital care]. / Prevalencia de procesos y patologías en la atención urgente hospitalaria.

OBJECTIVES: To study the behavioural differences between scheduled and emergency admissions in the processes most prevalent in Spanish hospitals and their relationship with the age of patients, comparing 2002 and 2007. METHODS: Observational and descriptive design for those years. Diagnostic related groups (DRGs) were classified into high prevalence (the 25 most frequent) and the rest; four subgroups were prepared according to this (high or low) and admission (elective or not). Mean length of stay was analyzed, together with relative weight, number of diagnoses and procedures and mortality by age, using the Student and/or ANOVA tests for quantitative variables and Pearson's chi(2) qualitative comparison of means and proportions for tabular data, assuming statistical significance at p <0.05. RESULTS: The high prevalence and emergency admission subgroup has higher age, ratio of males, mean length of stay, mortality, number of diagnoses and procedures (all p <0.0001), in both 2002 and 2007. The complexity and resource consumption measured by such variables peaks in the 65-69 and 70-74 cohorts respectively, with emergency admission. CONCLUSIONS: There are clear differences between the processes according to their prevalence and accessibility; priority must be given to knowledge and information on the most frequent and urgent admissions to improve the effectiveness, efficiency and quality.

Prevalencia de procesos y patologías en la atención urgente hospitalaria / Prevalence of processes and pathologies in emergency hospital care

Objetivos. Estudiar las diferencias de comportamientoentre ingresos urgentes y programados en los procesosmás prevalentes y el resto en la casuística hospitalariaespañola y su relación con la edad de los pacientes,comparando los años 2002 y 2007.Métodos. Diseño observacional y descriptivo duranteesos años. Se clasifican los grupos relacionados de diagnóstico(GRD) en alta prevalencia (25 más frecuentes)y resto, se confeccionan cuatro subgrupos según ésta(alta o baja) e ingreso (electivo o no). Se analiza estanciamedia, peso relativo, número de diagnósticos y procedimientosy mortalidad en función de la edad, por mediodel test de Student y/o ANOVA, según proceda, para variablescuantitativas y el de χ2 de Pearson para cualitativas,comparando ambas según análisis de datos ya tabulados.Se asume significación estadística para p<0,05.Resultados. El subgrupo de alta prevalencia e ingresourgente presenta mayor edad, proporción de varones,estancia media, mortalidad, número de diagnósticosy procedimientos (todo con p<0,0001), tanto en 2002como en 2007. La gravedad, complejidad y consumode recursos –medidos con esas variables– alcanza sumáximo en las cohortes de 65-69 y 70-74 años, respectivamente,con ingreso urgente.Conclusiones. Existen claras diferencias entre los procesos,según su prevalencia y acceso, y debe priorizarseel conocimiento y la información de los más frecuentesy urgentes para mejorar la efectividad, la eficienciay la calidad(AU)

Objectives. To study the behavioural differences betweenscheduled and emergency admissions in the processesmost prevalent in Spanish hospitals and theirrelationship with the age of patients, comparing 2002and 2007.Methods. Observational and descriptive design forthose years. Diagnostic related groups (DRGs) wereclassified into high prevalence (the 25 most frequent)and the rest; four subgroups were prepared accordingto this (high or low) and admission (elective or not).Mean length of stay was analyzed, together with relativeweight, number of diagnoses and procedures andmortality by age, using the Student and/or ANOVA testsfor quantitative variables and Pearson’s χ2 qualitativecomparison of means and proportions for tabular data,assuming statistical significance at p <0.05.Results. The high prevalence and emergency admissionsubgroup has higher age, ratio of males, mean lengthof stay, mortality, number of diagnoses and procedures(all p <0.0001), in both 2002 and 2007. The complexityand resource consumption measured by such variablespeaks in the 65-69 and 70-74 cohorts respectively, withemergency admission.Conclusions. There are clear differences between theprocesses according to their prevalence and accessibility;priority must be given to knowledge and informationon the most frequent and urgent admissions toimprove the effectiveness, efficiency and quality(AU)

Escalas de valoración del riesgo para el transporte interhospitalario de pacientes críticos: ¿índices de gravedad o de necesidad de soportes? / Scales for evaluating the risk of interhospital transfer of critical patients: Severity indices or indices of the need for support ?

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[The evaluation of autopsy in the pediatric intensive unit]. / Evaluación de la autopsia en la Unidad de Cuidados Intensivos Pediátricos.

OBJECTIVE: Because of concerns about the declining autopsy rate, an attempt was made to evaluate the contributions from the postmortem examination in children. PATIENTS AND METHODS: We carried out a retrospective comparison analysis between clinical and pathological diagnosis of 56 consecutive autopsies performed on children who died in the PICU during the period 1983-1995. RESULTS: The autopsy rate was 60%. Autopsy provided valuable clinical information in 50% of the cases. There were major diagnostic errors in three patients (5%), that if detected before death would probably have improved survival. Another 14 cases (25%) showed missed clinical diagnoses related to the basic illness and the cause of death, whose premortem diagnosis would not have prolonged survival. There were no diagnostic discrepancies in 28 cases (50%). The most unexpected findings revealed by the autopsies were iatrogenics (10 cases), metabolic diseases (4 cases), congenital immunodeficiency syndromes (4 cases) and pulmonary opportunistic infections (3 cases). Eight of these diseases were genetic. An age < 12 months or and ICU stay < 24 hours were not predicting factors of a higher incidence of major diagnostic errors. CONCLUSIONS: The value of the autopsy as quality assurance and to detect iatrogenics and occult genetic diseases is unquestionable. New strategies have to be designed to increase the rate of autopsies.

[Recurrent ARDS in varicella pneumonia complicated by disseminated candidiasis in a pregnant woman]. / SDRA recurrente tras neumonía varicelosa complicado con candidiasis diseminada en mujer gestante.

Adult respiratory distress syndrome (ARDS) seems to be the common way from different etiologies. We describe the clinical evolution of an ARDS in a pregnant woman, initially due to Varicella Pneumonia which was complicated with Disseminated Candidiasis and recurrent ARDS. We review the nosocomial infection with Candida in ICU patients: the growing incidence, the diagnostic problems and the new standards for treatment.