Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria / Analysis of organ failure and mortality in sepsis due to secondary peritonitis

Objetivos Identificar los órganos más propensos a desarrollar el síndrome de insuficiencia multiorgánica (MODS) en pacientes con sepsis por peritonitis secundaria. Determinar el valor evolutivo y predictivo de mortalidad del sistema Sequential Organ Failure Assessment (SOFA).Diseño Estudio de cohorte observacional prospectivo. Ámbito La unidad de reanimación (UR) de nuestro centro, un hospital universitario de tercer nivel. Pacientes Estudio prospectivo y observacional sobre 102 pacientes con sepsis de origen abdominal e insuficiencia de al menos un órgano relacionado con la infección. Se registraron las características demográficas, el origen abdominal de la sepsis, la mortalidad a los 28 días y la puntuación SOFA diaria. Resultados La mortalidad a los 28 días fue del 55%. El 53% de los pacientes presentaron fracaso de 2 o más órganos en el primer día de estancia. La puntuación SOFA media diaria fue significativamente mayor en los pacientes fallecidos a partir del cuarto día de estancia. Las variables que se asociaron a una mayor mortalidad de manera estadísticamente significativa fueron: MODS (p=0,000), fallo sistema nervioso central (p=0,000) y puntuación SOFA al cuarto día de estancia (p=0,012). El área bajo la curva ROC expresó una capacidad predictiva de mortalidad el SOFA cuarto día de estancia del 0,703 (IC 95%, 0,538-0,853 y p=0,026. El mejor poder discriminativo se observó para el MODS con área bajo la curva ROC del 0,776 (IC 95%, 0,678-0,874 y p=0,000).Conclusiones La evolución en la insuficiencia de órganos determinada por medio de SOFA mostró una alta precisión siendo un buen predictor de mortalidad la puntuación SOFA media cuarto día de estancia. El MODS fue la principal causa de muerte y el fracaso del sistema nervioso central, función renal y sistema respiratorio los factores de riesgo de muerte (AU)

Objectives To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. Design A prospective, observational cohort study was made. Setting The resuscitation unit of a third-level university hospital. Patients A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. Results The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000).Conclusions Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors (AU)

[Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. / Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria.

OBJECTIVES: To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN: A prospective, observational cohort study was made. SETTING: The resuscitation unit of a third-level university hospital. PATIENTS: A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS: The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS: Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.

Anestesia general combinada con analgesia epidural para ureteroneocistostomía en un paciente con síndrome de Cornelia de Lange / General anaesthesia combined with epidural analgesia for ureteroneocystostomy in a patient with Cornelia de Lange syndrome

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Anestesia en el paciente con alteración de la función hepática / Anesthesia in the patient with impaired liver function

Se ha analizado la información relevante relacionada con la alteración de la función hepática y el acto anestésico y la reanimación postoperatoria. Se ha analizado de manera sistemática la afectación hepática por sistemas y las complicaciones del paciente cirrótico según el tipo de cirugía. La corrección de la coagulopatía en el paciente cirrótico es especialmente controvertida, ya que la expansión de volumen puede ser un factor de sangrado al incrementar la presión portal y producir un desequilibrio entre los factores pro y anticoagulantes. La morbilidad y mortalidad perioperatorias se correlacionan bien con la clasificación de Child-Pugh y el MELD, de forma que los pacientes con Child A tienen un riesgo moderado y por ello no se contraindica la cirugía. Por el contrario, los pacientes en la clase C o con un valor de MELD superior a 20, no deben ser intervenidos de forma electiva por el elevado riesgo que tienen. En general se considera que la cirugía abdominal es de alto riesgo, ya que altera el flujo sanguíneo hepático y facilita la hemorragia quirúrgica debida a la hipertensión portal(AU)

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures(AU)

[Anesthesia in the patient with impaired liver function]. / Anestesia en el paciente con alteración de la función hepática.

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

[Fulminant hepatic failure and liver transplantation. Experience of the Hospital Virgen de la Arrixaca]. / Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca.

INTRODUCTION: Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of > 50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation. PATIENTS AND METHOD: A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis. CONCLUSIONS: The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

Asistencia a extranjeros en urgencias. Hospital Virgen de la Arrixaca / Health care for foreigners in the emergency service. Hospital Virgen de la Arrixaca

En España se han superado los 40 millones de habitantes y como en el resto de Europa el crecimiento de la población se hubiera enlentecido a no ser por la incorporación de emigrantes. Según el INE la población española puede crecer hasta el año 2025, teniendo en cuenta la entrada de emigrantes en nuestro país. El 74 por ciento de los emigrantes que llegan a nuestra Región proceden de América del Sur y de manera especial de Ecuador. A gran distancia están los que proceden del continente africano (16 por ciento) con una alta representación de Marruecos. El incremento de población extranjera en la Región de Murcia provoca un cambio social y demográfico, con un fiel reflejo en la utilización de los servicios sanitarios. Los pacientes extranjeros atendidos han sido seleccionados teniendo en cuenta la cumplimentación, cuando ha existido, del campo país de nacimiento. Se han analizado 335.348 urgencias asistidas durante los años 2000 y 2001, extraídas de registros del Sistema de Información del Hospital Virgen de la Arrixaca de Murcia. De ellas, 11.602 han cumplido los requisitos para el estudio de urgencias, de las cuales el 19 por ciento ingresan. La evolución es ascendente y ha supuesto pasar de 4.674 pacientes en 2000 a 6.928 en 2001. En el desglose por meses de esta atención destaca la periodicidad casi simétrica en cada uno de los meses estudiados. En cuanto a días de la semana destaca el aumento de pacientes en urgencias los sábados, domingos y lunes. Al analizar el perfil del ciudadano inmigrante que acude a urgencias se detecta un gran impacto de las mujeres en edad fértil, que explicaría, posiblemente, el incremento de natalidad en la Región de Murcia (AU)