Valoración de la capacidad preoperatoria al ejercicio como factor predictivo de supervivencia en enfermos sometidos a trasplante pulmonar / Evaluation of the pre-operative exercise capacity as survival marker in the lung transplant recipients

Objetivo. Evaluar de manera independiente la capacidad al ejercicio como factor predictivo de supervivencia en el trasplante pulmonar. Diseño. Estudio retrospectivo. Ámbito. Unidad de trasplante pulmonar de la Unidad de Cuidados Intensivos (UCI) de un hospital universitario. Pacientes. Se realizaron y analizaron 132 trasplantes pulmonares, en un total de 130 enfermos. El seguimiento de cada caso se realizó hasta fecha de 18 de junio de 2005 o fallecimiento del paciente. Variables de interés. Se valoró la capacidad preoperatoria al ejercicio mediante la prueba de marcha de los 6 minutos (PM6M). También se valoró la supervivencia a largo plazo en relación con el valor obtenido en la PM6M. Las curvas de supervivencia se estimaron por el método de Kaplan-Meier; la comparación entre curvas se hizo por el método de Log-Rank y las hazard ratios se estimaron por regresión de Cox. Resultados. El estudio de asociación a mortalidad de la PM6M mostró un riesgo relativo de 0,99 (intervalo de confianza del 95%: 0,99-1,00) por cada unidad de medida métrica (metro) (p = 0,282). Se clasificó a los enfermos según la distancia recorrida en 4 grupos: grupo I (distancia recorrida menor de 100 metros), grupo II (distancia recorrida entre 101-200 metros), grupo III (distancia recorrida entre 201 y 300 metros) y grupo 4 (distancia mayor de 301 metros). No se encontraron diferencias significativas al comparar las curvas de supervivencia entre los grupos (p = 0,709). El análisis multivariante tampoco aportó significación estadística. Conclusión. La distancia recorrida en la PM6M realizada en el protocolo de estudio de candidatos a trasplante pulmonar no creemos que sea útil como marcador de mortalidad a largo plazo en los enfermos sometidos a recambio pulmonar

Objective. To make an independent evaluation of the capacity for exercise as a predictive factor in lung transplant recipients. Design. Retrospective study. Scope. Lung transplant unit of the Intensive Care Unit (ICU) of a university hospital. Patients. We analyzed 132 lung transplants in a total of 130 patients. The patients were monitorized up to June 18, 2005 or their death. Variables of interest. An evaluation was made of their pre-operative exercise capacity with the 6-minute walking test (6MWT). Long-term survival in relationship with the walking test value was also assessed. The survival curves were estimated using the Kaplan-Meier method. Comparison between curves was made with the Log-Rank methods and the hazard ratios were estimated by Cox regression. Results. The association between mortality and the walking test value showed a hazard ratio of 0.99 (95% CI: 0.99-1.00) per metric unit (meter), (p = 0.282). The patients were classified according to the distance covered in the 4 groups: group 1 (distance covered less than 100 meters), group II (distance covered between 101-200 meters), group III (distance covered between 201 and 300 meters) and group IV (distance greater than 301 meters). No significant differences were found when comparing the survival curves of the four groups (p = 0.709). The multivariant analysis also did not show any statistical significance. Conclusions. We do not believe that the distance covered in the 6MWT conducted in the study protocol in the lung transplant candidates is useful as a marker to predict long-term mortality in patients undergoing lung transplant

[Evaluation of the pre-operative exercise capacity as survival marker in the lung transplant recipients]. / Valoración de la capacidad preoperatoria al ejercicio como factor predictivo de supervivencia en enfermos sometidos a trasplante pulmonar.

OBJECTIVE: To make an independent evaluation of the capacity for exercise as a predictive factor in lung transplant recipients. DESIGN: Retrospective study. SCOPE: Lung transplant unit of the Intensive Care Unit (ICU) of a university hospital. PATIENTS: We analyzed 132 lung transplants in a total of 130 patients. The patients were monitorized up to June 18, 2005 or their death. VARIABLES OF INTEREST: An evaluation was made of their pre-operative exercise capacity with the 6-minute walking test (6MWT). Long-term survival in relationship with the walking test value was also assessed. The survival curves were estimated using the Kaplan-Meier method. Comparison between curves was made with the Log-Rank methods and the hazard ratios were estimated by Cox regression. RESULTS: The association between mortality and the walking test value showed a hazard ratio of 0.99 (95% CI: 0.99-1.00) per metric unit (meter), (p = 0.282). The patients were classified according to the distance covered in the 4 groups: group 1 (distance covered less than 100 meters), group II (distance covered between 101-200 meters), group III (distance covered between 201 and 300 meters) and group IV (distance greater than 301 meters). No significant differences were found when comparing the survival curves of the four groups (p = 0.709). The multivariant analysis also did not show any statistical significance. CONCLUSIONS: We do not believe that the distance covered in the 6MWT conducted in the study protocol in the lung transplant candidates is useful as a marker to predict long-term mortality in patients undergoing lung transplant.

[Training in the care of the critical and multiple-injured patient: role of clinical simulation]. / Formación en la asistencia al paciente crítico y politraumatizado: papel de la simulación clínica.

Clinical simulation is suggested as a new educational instrument to learn and train in different medical skills. It is conceived as a new method that integrates scientific knowledge and human factors. Experience with these systems has been limited up to now, but it is now being widely accepted since it seems to accelerate acquisition of skills and knowledge in a safe setting, that is, without risk for the patient. However, its effect on clinical performance has not been validated yet. They are two types of simulators for intensive cares: screen based and human patient simulator (HPS). These systems make it possible to simulate different situations that require the application of action protocols or the management of new drugs in the clinical practice, promoting the rational use of resources in urgent care of the critical and multiple-injured patients. The limiting factors that prevent the expansion of the simulation for clinical training are its high cost, human resources needed, and the difficulties to assess the effectiveness of the training in real situations.

Formación en la asistencia al paciente crítico y politraumatizado: papel de la simulación clínica / Training in the care of the critical and multiple-injured patient: role of clinical simulation

La simulación clínica está surgiendo como un nuevo instrumento educativo para aprender y entrenar diferentes habilidades médicas. Está concebida como un novedoso método que integra conocimiento científico y factores humanos. La experiencia con estos sistemas es hasta ahora limitada, pero está siendo ampliamente aceptada, ya que parece acelerar la adquisición de habilidades y conocimientos en un ambiente seguro, es decir, sin riesgo para el paciente; si bien su efecto en el rendimiento clínico aún no ha sido validado. Hay dos tipos de simuladores para cuidados intensivos: de pantalla y simuladores de paciente a escala real (SER). Estos sistemas permiten simular distintas situaciones que requieren la aplicación de protocolos de actuación o el manejo de nuevos fármacos en la práctica clínica, fomentando el uso racional de recursos en la asistencia urgente del paciente crítico y politraumatizado. Los factores limitantes que impiden la expansión de la simulación para el entrenamiento clínico son su alto coste, los recursos humanos necesarios y las dificultades para valorar la efectividad del entrenamiento en situaciones reales

Clinical simulation is suggested as a new educational instrument to learn and train in different medical skills. It is conceived as a new method that integrates scientific knowledge and human factors. Experience with these systems has been limited up to now, but it is now being widely accepted since it seems to accelerate acquisition of skills and knowledge in a safe setting, that is, without risk for the patient. However, its effect on clinical performance has not been validated yet. They are two types of simulators for intensive cares: screen based and human patient simulator (HPS). These systems make it possible to simulate different situations that require the application of action protocols or the management of new drugs in the clinical practice, promoting the rational use of resources in urgent care of the critical and multiple-injured patients. The limiting factors that prevent the expansion of the simulation for clinical training are its high cost, human resources needed, and the difficulties to assess the effectiveness of the training in real situations

[Herpetic encephalitis in adults: 23 cases]. / Encefalitis herpética en adultos: 23 casos.

OBJECTIVE: To study the clinical presentation, diagnosis, treatment and prognosis of the herpetic encephalitis in our environment. MATERIAL AND METHOD: During the past 12 years, 23 adults (age > 15 years) were treated for herpetic encephalitis in our centre. RESULTS: There were 14 males and 9 females. Ages ranged from 18 to 84 years (mean, 52.30 +/- 18.64 years). The hospital stay ranged from 5 to 64 days (mean, 26.74 +/- 15.41 days). Eleven patients were managed in the intensive care unit and nine patients required mechanical ventilation. The most frequent clinical features they were the level of conscience decrease and fever. The lymphocytic pleiocytosis was the most frequent discovery in cerebrospinal fluid. The temporal lobe lesions in the computed tomography scan appeared in 14 patients (61%). Four patients died, seven patients were asymptomatic or with minimum sequels and twelve patients developed they were disabled. CONCLUSIONS: The herpetic encephalitis is an uncommon illness. Intravenous acyclovir is recommended treatment and the corticosteroids use is controverted. The delay in the treatment beginning worsens the prognosis. Less than a third of the patients achieve the functional independence to discharge hospital.

Encefalitis herpética en adultos: 23 casos / Herpetic encephalitis inadults: 23 cases

Objetivo: Estudiar la presentación clínica, diagnóstico, tratamiento y pronóstico de la encefalitis herpética en nuestro medio. Material y método: Estudio retrospectivo de los pacientes mayores de 15 años que ingresaron en nuestro hospital por encefalitis herpética en los últimos 12 años. Resultados: Se incluyeron 23 pacientes, 14 varones y 9 mujeres. La edad media era de 52,30 ± 18,64 años (rango 18-84). La estancia media en el hospital fue de 26,74 ± 15,41 días (rango 5-64). Ingresaron en UCI 11 pacientes, requiriendo 9 ventilación mecánica. Los hallazgos clínicos más habituales fueron la alteración del nivel de conciencia y la fiebre. La pleocitosis linfocitaria fue el hallazgo más frecuente en el líquido cefalorraquídeo. Se encontraron lesiones temporales por tomografía en 14 enfermos (61%). Fallecieron 4 pacientes, quedando asintomáticos o con mínimas secuelas 7 y 12 desarrollaron secuelas incapacitantes. Conclusiones: La encefalitis herpética es una enfermedad poco frecuente. El tratamiento de elección es el aciclovir endovenoso y el uso de corticoides es controvertido. El retraso en el inicio del tratamiento empeora el pronóstico. Menos de un tercio de los pacientes consiguen la independencia funcional al alta

Objective: To study the clinical presentation, diagnosis, treatment and prognosis of the herpetic encephalitis in our environment. Material and method: During the past 12 years, 23 adults (age > 15 years) were treated for herpetic encephalitis in our centre. Results: There were 14 males and 9 females. Ages ranged from 18 to 84 years (mean, 52,30 ± 18,64 years). The hospital stay ranged from 5 to 64 days (mean, 26,74 ± 15,41 days). Eleven patients were managed in the intensive care unit and nine patients required mechanical ventilation. The most frecuent clinical features they were the level of conscience decrease and fever. The lymphocytic pleiocytosis was the most frequent discovery in cerebrospinal fluid. The temporal lobe lesions in the computed tomography scan appeared in 14 patients (61%). Four patients died, seven patients were asymptomatic or with minimum sequels and twelve patients developed they were disabled. Conclusions: The herpetic encephalitis is on uncommon illness. Intravenous acyclovir is recommended treatment and the corticosteroids use is controverted. The delay in the treatment beginning worsens the prognosis. Less than a third of the patients they achieve the functional independence to discharge hospital

Neumonía varicelosa en adultos: 30 casos / Varicella pneumonia in adults: 30 cases

Objetivos: Estudio retrospectivo de los pacientes >15 años que ingresaron en nuestro hospital por neumonía varicelosa en los últimos 10 años. Métodos: Se incluyeron 30 pacientes, 16 varones y 14 mujeres. La edad media era de 32,73 ± 7,67 años (Rango: 15-58). El 90 por ciento eran fumadores y 3 estaban embarazadas. La estancia media en el hospital fue de 14,96 ± 12,02 días (Rango: 4-57). Resultados: Ingresaron en UCI 7 pacientes y 2 necesitaron ventilación mecánica. El infiltrado intersticial (70 por ciento) y el alveolo-intersticial (23 por ciento) fueron los patrones radiológicos más frecuentes. La auscultación pulmonar fue normal en 2/3. Los hallazgos clínicos más frecuentes fueron: fiebre (100 por ciento), tos seca (86,6 por ciento), disnea (66,6 por ciento) y dolor pleurítico (50 por ciento). El índice pO2/FiO2 fue <=300 en 15 casos. El 50 por ciento presentaron hiponatremia y el 40 por ciento trombopenia. Falleció un paciente, otro evolucionó a una fibrosis pulmonar y tres desarrollaron, posteriormente, asma. Conclusiones: La neumonía varicelosa en adultos suele presentarse en individuos fumadores. Se debe realizar Rx tórax a todos los pacientes adultos con varicela e ingresar las neumonías. El tratamiento de elección es el Aciclovir endovenoso y en enfermos graves puede considerarse la asociación de corticoides (AU)

Trombosis de la arteria basilar y ventilación mecánica / Basilar artery thrombosis and mechanical ventilation

Introducción: Conocer la incidencia, factores de riesgo, complicaciones y pronóstico de los pacientes con trombosis de la arteria basilar grave. Material y métodos: Se revisaron de forma retrospectiva todos los pacientes diagnosticados de trombosis basilar que fueron conectados a ventilación mecánica en nuestro hospital durante un periodo de 10 años (11-1989 hasta el 31-12-1998). Se analizaron los siguientes datos: sexo, edad, factores de riesgo, causa de intubación, días de estancia en la UCI y en el hospital, el pronóstico a los 3 y 6 meses y las causas de fallecimiento. Resultados: De los 24 casos encontrados, el 62,5 por ciento fueron varones. La edad media entre los supervivientes y los fallecidos fue similar (60,1 ± 16 y 62 ± 15,8 años). Los factores de riesgo más frecuentes fueron la hipertensión arterial, la fibrilación auricular, la diabetes mellitus y el tabaquismo. La estancia media en UCI fue 11,2 ± 14,8 días y en el hospital 31,9 ± 58,6 días. Las causas de intubación fueron: coma, protección de la vía aérea, parada cardio-respiratoria, crisis convulsivas generalizadas e infección respiratoria. La mortalidad fue del 75 por ciento, siendo causada por progresión del coma o infecciones. El 16 por ciento de los pacientes lograron una buena recuperación. Conclusiones: Los pacientes que ingresaron en coma, en parada cardio-respiratoria reanimada y aquellos que presentaron crisis convulsivas generalizadas o neumonía tuvieron una mayor mortalidad. Se debe prestar especial atención a la aparición de hidrocefalia e infecciones por la importancia de un tratamiento precoz. En los pacientes con deterioro progresivo del nivel de conciencia la protección de la vía aérea quizás mejore el pronóstico (AU)

[Thrombosis of the basilar artery and mechanical ventilation]. / Trombosis de la arteria basilar y ventilación mecánica.

BACKGROUND: To know the incidence, risk factors, complication and prognosis of the serious thrombosis of the basilar artery. METHODS: All patients diagnosed as having basilar thrombosis during a 10 year period (1/1/1989 to 31/12/1998) and having been connected to mechanical ventilation in our hospital are retrospectively revised. The following data are analysed: gender, age, risk factors, cause of intubation, days of stay at the intensive care unit and at the hospital, the prognosis at 3 and 6 months and the causes of decease. RESULTS: 62.5% of the 24 found cases were males. The average age among the survivors and the decreased was similar (60.1 +/- 16 and 62 +/- 15.8 years). The most common risk factors were high blood-pressure, atrial fibrillation, diabetes mellitus and smoking. The average stay at the intensive care unit was 11.2 +/- 14.8 days and 31.9 +/- 58.6 days at the hospital. The cause of intubation were: coma, airway protection, cardiorespiratory arrest, general convulsive crisis and respiratory infection. Mortality reached 75% and was caused by progression of coma or infections. Only 16% of them recovered satisfactorily. CONCLUSIONS: The patients admitted to hospital in coma, in revived cardiorespiratory arrest and those presenting general convulsive crisis or pneumonia have a higher mortality. Special attention must be drawn towards the appearance of hydrocephalus and infections due to the importance of an early treatment. In patient with a progressive damage of the consciousness level, the airway protection might improve the prognosis.

[Chylothorax secondary to blunt thoracic trauma. Report of 6 cases]. / Quilotórax secundario a traumatismo torácico cerrado. A propósito de 6 casos.

Chylothorax is a rare condition that even more rarely arises as a result of closed thoracic trauma. We report a series of 6 patients who suffered chylothorax after closed trauma, who were diagnosed early and treated conservatively. Either total parenteral feeding or adjusted enteral feeding, depending with circumstances, was started early such that complications from chylothorax were few. Surgery was required in only one case, and outcomes were satisfactory in all patients, none of whom died.

[Independent pulmonary ventilation as a treatment in the re-expansion of atelectasis]. / Ventilación pulmonar independiente como tratamiento en la reexpansión de atelectasias.

Two patients with respiratory failure were treated with independent lung ventilation (ILV). During their clinical course they developed atelectasis without response to usual therapies. The use of ILV and selective positive end-expiratory pressure (S-PEEP) allowed lung expansion and oxymetric improvement. With the ILV plus S-PEEP we tried to correct the abnormal ventilation/perfusion ratio. ILV plus S-PEEP increases both the ventilation in the highly perfused areas, and the functional residual capacity selectively in the pathologic lung in unilateral affection cases.

[Double tachycardia (hisian and auricular) in a bradycardia-tachycardia syndrome (author's transl)]. / Doble taquicardia (hisiana y auricular) en un síndrome bradicardia-taquicardia.

The present case corresponds to a patient with a mitro-aortic valvulopathy of rheumatic origin with syncopal episodes and nauseas, who, in the ECG showed alternatively an extreme sinusal bradycardia and supraventricular tachyarrhythmias. It was interpreted as a typical case of bradycardia-tachycardia syndrome in which the crises of tachyarrhythmias consisted of episodes of double tachycardia with incomplete supra-hisian atrial-ventricular dissociation, documented by obtaining right atrial electrograms and hisian-electrograms during the episodes. Treatment was initiated with verapamil (10 mg intravenously every 8 hours) after an endocavitary pacemaker of demand had been placed. After 3 months the result was very satisfactory with good tolerance to the medical treatment and complete disappearance of the symptomatology.