Síndrome de Kounis / Kounis syndrome

El síndrome de Kounis (SK) fue descrito en 1991 por Kounis y Zavras como la aparición simultánea de eventos coronarios agudos y reacciones alérgicas anafilácticas o anafilactoides. Engloba conceptos como el de angina alérgica e infarto alérgico y se ha descrito en relación con picaduras de insectos, ingesta de fármacos y alimentos, exposiciones ambientales y condiciones médicas varias. Se desconoce su incidencia real ya que, la mayoría de la información proviene de casos clínicos o pequeñas series. En el presente artículo se exponen los aspectos clínicos, diagnósticos, fisiopatología y tratamiento de este síndrome (AU)

Kounis syndrome was described in 1991 by Kounis and Zavras as the coincidental occurrence of acute coronary syndromes with allergic reactions (anaphylactic or anaphylactoid). Today, allergic angina and allergic myocardial infarction are referred to as Kounis syndrome, and the latter has been reported in association with a variety of drugs, insect stings, food, environmental exposures and medical conditions, among other factors. The incidence is not known, as most of the available information comes from case reports or small case series. In this article, the clinical aspects, diagnosis, pathogenesis, related conditions and therapeutic management of the syndrome are discussed (AU)

[Kounis syndrome]. / Síndrome de Kounis.

Kounis syndrome was described in 1991 by Kounis and Zavras as the coincidental occurrence of acute coronary syndromes with allergic reactions (anaphylactic or anaphylactoid). Today, allergic angina and allergic myocardial infarction are referred to as Kounis syndrome, and the latter has been reported in association with a variety of drugs, insect stings, food, environmental exposures and medical conditions, among other factors. The incidence is not known, as most of the available information comes from case reports or small case series. In this article, the clinical aspects, diagnosis, pathogenesis, related conditions and therapeutic management of the syndrome are discussed.

Predicción de la utilidad clínica de la radiografía de tórax rutinaria en una unidad de cuidados intensivos de traumatología / Prediction of the clinical usefulness of routine chest X-rays in a traumatology ICU

IntroducciónEl valor de la radiografía torácica rutinaria está en cuestión. Sin embargo, este asunto no ha sido suficientemente evaluado en el caso concreto del paciente traumatizado. Nos propusimos encontrar predictores de utilidad en este entorno.Material y métodosEstudio observacional prospectivo en una UCI de traumatología de 8 camas. Se incluyeron los pacientes de más de 15 años, con traumatismo grave (ISS > 15), ingresados 48h o más. Se excluyeron las mujeres embarazadas y las radiografías no rutinarias. Un miembro del equipo médico examinó de manera independiente las placas, en busca de hallazgos radiográficos según se definían en una lista cerrada. Durante la ronda diaria, los médicos al cargo comunicaron cuantos cambios en el estado clínico y en el manejo ocurrieron tras la toma de la radiografía, también siguiendo una lista de criterios cerrados. La relación entre ambas variables se estudió por análisis univariante y multivariante.ResultadosDurante un año se obtuvieron 1.440 radiografías de 138 pacientes consecutivos. Predominaron los varones (82%), de edad joven (39±1 años). El 97% sufrieron traumatismo contuso; el 52%, traumatismo torácico grave. La estancia media se prolongó 12,9±10,1 días. En el 86,8% se empleó ventilación mecánica. De cada paciente se realizaron 10,4±9,3 placas. En el 14% hubo hallazgos relevantes, con mayor frecuencia una malposición de un dispositivo (6,8%) o infiltrados (4,9%), desencadenando una acción clínica en el (..) (AU)

AbstractBackground: The clinical value of routine chest X-rays in critical care has been questioned, buthas not been studied in the trauma environment to date. The objective of this study was toidentify easy to use clinical predictors of utility in this setting.Material and methods: A prospective observational study was made in an 8-bed traumatologyICU. Severe trauma patients (ISS > 15), aged 15 or older and admitted for 48 h or longer wereincluded. Pregnant women and radiographs obtained during initial care or for reasons otherthan routine indication were excluded. A staff physician, separated from clinical duties, independentlyreviewed the films in search of changes, as described in a closed checklist. Followingclosed criteria, the attending physicians reported previous day clinical events and changes inclinical management after chest X-ray obtainment. Demographic and epidemiological data werealso recorded. The associations among variables were studied by univariate and multivariateanalysis.Results: A total of 1440 routine chest X-rays were obtained from 138 consecutive patientsduring one year. Young males prevailed (82%; 39±16 years). The most common process wassevere blunt trauma (97%). Fifty-two percent suffered severe chest trauma. The mean lengthof stay was 12.9±10.1 days. Mechanical ventilation was used in 86.8% of the cases. A medianof 10.4±9.3 films were obtained from each patient. A total of 14% of the X-rays showed changes,most commonly malpositioning of an (..) (AU)

[Prediction of the clinical usefulness of routine chest X-rays in a traumatology ICU]. / Predicción de la utilidad clínica de la radiografía de tórax rutinaria en una unidad de cuidados intensivos de traumatología.

BACKGROUND: The clinical value of routine chest X-rays in critical care has been questioned, but has not been studied in the trauma environment to date. The objective of this study was to identify easy to use clinical predictors of utility in this setting. MATERIAL AND METHODS: A prospective observational study was made in an 8-bed traumatology ICU. Severe trauma patients (ISS > 15), aged 15 or older and admitted for 48 h or longer were included. Pregnant women and radiographs obtained during initial care or for reasons other than routine indication were excluded. A staff physician, separated from clinical duties, independently reviewed the films in search of changes, as described in a closed checklist. Following closed criteria, the attending physicians reported previous day clinical events and changes in clinical management after chest X-ray obtainment. Demographic and epidemiological data were also recorded. The associations among variables were studied by univariate and multivariate analysis. RESULTS: A total of 1440 routine chest X-rays were obtained from 138 consecutive patients during one year. Young males prevailed (82%; 39 ± 16 years). The most common process was severe blunt trauma (97%). Fifty-two percent suffered severe chest trauma. The mean length of stay was 12.9 ± 10.1 days. Mechanical ventilation was used in 86.8% of the cases. A median of 10.4 ± 9.3 films were obtained from each patient. A total of 14% of the X-rays showed changes, most commonly malpositioning of an indwelling device (6.8%) or infiltrates (4.9%). Those findings led to a change in care in 84.6% of the cases. Multivariate analysis identified the following significant (p < 0.05) risk factors for radiographic changes: first two days of evolution, mechanical ventilation, worsening of PaO2/FiO2, worsening of lung compliance and changes in respiratory secretions. CONCLUSIONS: Based on the results obtained, the risk of not identifying dangerous conditions by restricting routine chest X-rays prescription to the described conditions is low. Observing this policy would probably mean substantial savings and a reduction in radiation exposure.

Descontaminación: un tratamiento sin indicaciones / Decontamination. A treatment without indications

La prevención de la neumonía asociada a la ventilación mecánica (NAV) es un objetivo prioritario en las unidades de cuidados intensivos (UCI). Para conseguirlo, las guías de práctica clínica recomiendan la aplicación simultánea de un conjunto heterogéneo de medidas que ha mostrado su efectividad, de manera que en la actualidad se asiste a una reducción de la incidencia de la NAV hasta cifras que hasta hace poco se consideraban inalcanzables; un mayor cumplimiento de las guías de práctica clínica se ha traducido en múltiples estudios en tasas de NAV que se aproximan a cero. Frente a las medidas recomendadas en las guías de práctica clínica, la descontaminación digestiva selectiva (DDS), aplicada junto con otras medidas de control de infecciones, ha mostrado eficacia en hospitales con elevada incidencia basal de neumonía, pero su efectividad en hospitales con buen cumplimiento de las guías de práctica clínica y tasas bajas de NAV es altamente improbable. Un serio inconveniente de la DDS es el riesgo de favorecer la selección de microorganismos resistentes, que pueden diseminarse fácilmente por la unidad de cuidados intensivos y el hospital. Con los estándares actuales de prevención de infecciones, la DDS es una medida innecesaria y de riesgo, que no debe emplearse de manera generalizada. Aún no se conoce en qué situaciones la DDS puede aumentar la efectividad de las medidas preventivas estándares correctamente aplicadas (AU)

The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown (AU)

[Decontamination. A treatment without indications]. / Descontaminación: un tratamiento sin indicaciones.

The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.

[Loco-regional analgesia]. / Analgesia locorregional.

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection).

Analgesia locorregional / Loco-regional analgesia

La analgesia epidural es una de las técnicas más eficaces para el alivio del dolor cuando está indicada, pero puede presentar complicaciones potencialmente graves que deben ser diagnosticadas y tratadas precozmente. Se emplea en Medicina Intensiva en el control del dolor posoperatorio y tras traumatismo grave. La técnica es sencilla: se coloca un catéter en una cavidad virtual permitiendo que los anestésicos locales difundan hasta las raíces nerviosas raquídeas. La administración de anestésicos locales, opiáceos o la combinación de ambos por vía epidural (ad- ministrados de forma intermitente o en infusión continua) proporciona una mejor analgesia. También puede emplearse la clonidina. Para diagnosticar y tratar adecuadamente las posibles complicaciones (dolor, retención urinaria, náuseas y vómitos, prurito, bloqueo motor, infección, depresión respiratoria e hipotensión) deben adoptarse una serie de medidas de seguridad (monitorización respiratoria y hemodinámica, nivel de consciencia, nivel sensitivo, ritmo de diuresis y signos de infección) (AU)

The epidural analgesia is one of the most effective techniques for pain relief when it is indicated, but it can present potentially serious complications that must precociously be diagnosed and be treated. In the Critical Care setting, epidural analgesia is used for pain control after surgery or major trauma. The technique is simple, a catheter is placed into a virtual cavity, so the administered drugs are absorbed through the epidural space into nerve roots. The administration of local anesthetics, opioids or the combination of both by epidural route (administered in continuous infusion or bolus), provides better analgesia. Also the clonidine can be used. In order to diagnose and to treat suitably the possible complications (pain, urinary retention, nauseas and vomits, itching, motor block, infection, respiratory depression, hypotension) a series of safety measures must be adopted (respiratory and heart rate, blood pressure, sedation score, sensory and motor level assessment, rate of diuresis, temperature and signs of infection) (AU)