Guía de acceso vascular en hemodiálisis / Vascular access guideliness for hemodialysis

Introducción. La calidad del acceso vascular (AV) condiciona los resultados clínicos de los enfermos tratados mediante hemodiálisis periódicas. Las complicaciones originadas por la disfunción del AV constituyen una de las principales causas de morbimortalidad de estos pacientes y contribuyen de forma sustancial al aumento del coste sanitario. La Sociedad Española de Nefrología considera que este problema requiere una atención prioritaria, y ha decidido realizar una revisión de las guías de actuación de este capítulo, con la finalidad de mejorar nuestros estándares colectivos y elevar la calidad de nuestra práctica asistencial. Objetivos. La finalidad esencial ha sido la de elaborar un informe que pueda proporcionar una ayuda para la comprensión y tratamiento de los problemas relacionados con el AV y obtener una homogeneización de actuaciones con el propósito de alcanzar tres objetivos principales: aumentar la utilización de fístulas arteriovenosas autólogas como AV inicial, detectar la disfunción de AV permanente antes de la trombosis y racionalizar la utilización de catéteres venosos centrales (CVC). Desarrollo y conclusiones. Se presenta un documento consensuado de forma multidisciplinar en la que han participado nefrólogos, cirujanos vasculares, radiólogos intervencionistas, especialistas en enfermedades infecciosas y diplomados en enfermería nefrológica. En él se define el estado de la situación en seis capítulos: preparación del paciente, creación del AV, cuidados, vigilancia, tratamiento de las complicaciones y CVC. Estas guías constan de una serie de enunciados con diferentes grados de evidencia según la literatura disponible, que no pretenden ser normas de obligado cumplimiento, sino referentes del estado actual del problema y sus soluciones. La práctica clínica diaria, al depender de las condiciones intrínsecas, no siempre nos permite alcanzar el ideal, pero sí dirigir nuestros esfuerzos a una mejora de resultados. Cada recomendación se complementa con la exposición de su razonamiento. El documento se acompaña de una serie de indicadores de calidad

Introduction. Quality of vascular access (VA) has aremarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Aims. Spanish Society of Nephrology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. Development and conclusions.We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care ,monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to take aproppiate decissions. Several quality standars are also included

Tratamiento empírico de la neumonía adquirida en la comunidad / Empirical treatment of community-acquired pneumonia

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[Prosthetic valve endocarditis]. / Endocarditis protésica.

Infective endocarditis occurs in 4% of prosthetic valve carriers. The infection is related to both the injured endocardium and circulating microorganisms. Early prosthetic endocarditis, occurring in the first 12 months after valvular surgery is mainly caused by staphylococci, and late prosthetic endocarditis has a similar etiology as native valve endocarditis. Clinical manifestations of early cases are due to both bacteremia and prosthetic malfunction. In late cases the clinical picture is similar to native valve disease. Mortality in prosthetic endocarditis remains high, especially in early cases, despite combined medical and surgical treatment.

[Meningitis caused by Staphylococcus aureus. Analysis of 16 cases]. / Meningitis por Staphylococcus aureus. Análisis de dieciséis casos.

During the period between 1982 and 1987, 16 cases of meningitis due to Staphylococcus aureus were diagnosed. Nine patients (56%) had undergone a previous neurosurgical operation and 5 of them were carriers of a cerebrospinal fluid (CSF) shunt. Seven patients (44%) had spontaneous meningitis. Fever and meningeal signs were the most common clinical findings. 50% of patients were comatose. The Gram stain of CSF showed Gram positive cocci in 7 cases. Blood cultures were positive in all patients with spontaneous meningitis and negative in the neurosurgical group. Overall mortality rate was 37.5%, and it was lower in the neurosurgical group than in the spontaneous meningitis. Other factors associated with a poor outcome were advanced age, bacteremia and septic shock.

[Pyogenic liver abscess. Review of 33 cases]. / Absceso piógeno hepático. Revisión de 33 casos.

Thirty three cases of pyogenic liver abscess, (24 single and 9 multiple), diagnosed in our department during the past 6 years, were reviewed. Mean patient age was 54 years with a male predominance over females (1.5:1). The most frequently encountered underlying pathology was bile duct disease (33%), followed by previous liver disease (21%). Causal pathology could not be found in 4 cases (12%). The most frequent sign was fever (76%). Diagnosis was made by clinical picture and complementary exam (echography, CT scan and hepatic gammagraphy) in 29 cases (88%). Blood and pus cultures were positive in 47 and 67% of cases respectively. Thirty nine per cent of microbial abscesses were polymicrobial. E. coli and S. milleri were the most frequently isolated. No micro-organism were identified in 5 cases (15%). Antibiotic treatment was given to 33 patients. Surgical drainage was performed in 24 cases and percutaneous drainage in 7 patients. Two patients received antibiotics exclusively. Five patients died (15%), three of whom had a multiple abscess (33%) and the other two had a single abscess (8%). The efficacy of percutaneous drainage for diagnosis and treatment is analyzed reviewing recent literature.