[Infections in critically ill patients]. / Infecciones en el paciente crítico.

INTRODUCTION: Infections are very frequent in patients who are admitted to Intensive Care Units, sometimes being a reason for admission and in others the infection is acquired during ICU stay. EPIDEMIOLOGY: The most frequent causes of acquired infection in the community that require admission to the ICU are respiratory infections, urinary tract infections and infections of the central nervous system. Among the infections acquired in the ICU, devices-associated infections are the most frequent. ETIOLOGY: The most frequent in ICU are Gram negative pathogens. ETIOPATHOGENESIS: In the critical patient, several factors are combined making them especially vulnerable to infections. CLINICAL MANIFESTATIONS: Depends on the location of the infection. DIAGNOSIS: It must be early due to its increased mortality. PROGNOSIS: Nosocomial infections are associated with an increase in mortality and in the length of stay. TREATMENT: The delay in treatment is associated with an increase in mortality.

[Infectious spondylodiskitis and epidural abscess after spinal puncture for pilonidal sinus excision]. / Espondilodiscitis infecciosa y absceso epidural después de una punción subaracnoidea para escisión de sinus pilonidal.

Vertebral infections after spinal puncture are rare and often inadequately documented. Their incidence does not exceed that of spontaneous epidural abscesses and we should therefore be cautious about assuming a causal relation between puncture and an abscess. After analyzing 10 published cases we saw that only half of them reported on aseptic conditions and only 2 patients seem to have had a prior infection. In 3 cases, the abscesses appeared after technically simple punctures whereas half the reports did not even mention the type of puncture. This complication should be considered whenever a patient develops back pain and fever, even if there are no neurological deficits and even after a simple spinal puncture. Given that early diagnosis and treatment have proven effective in improving the survival rate and reducing the rate of neurological sequelae, magnetic resonance images should be ordered urgently so that early treatment can be established.

Espondilodiscitis infecciosa y absceso epidural después de una punción subaracnoidea para escisión de sinus pilonidal / Infectious spondylodiskitis and epidural abscess after spinal puncture for pilonidal sinus excision

Las infecciones vertebrales tras punción subaracnoidea son excepcionales y a menudo están insuficientemente documentadas. Su incidencia no supera la de los abscesos epidurales espontáneos, lo que debería obligarnos a ser prudentes antes de afirmar la relación causal entre punción y absceso. Tras analizar 10 casos publicados observamos que sólo en la mitad de ellos se aportan datos sobre las condiciones de asepsia de las punciones y únicamente en dos pacientes parece haber una infección previa. En tres casos los abscesos aparecen tras punciones técnicamente sencillas, mientras que en la mitad de ellos ni siquiera se menciona este evento. Debe considerarse esta complicación ante un paciente con dolor de espalda y fiebre, aunque no aparezcan déficit neurológicos, e incluso tras punción subaracnoidea sencilla. Es importante solicitar urgentemente una resonancia magnética, con el fin de establecer con premura un tratamiento adecuado, puesto que el diagnóstico y tratamiento precoces han demostrado su eficacia para mejorar la supervivencia y disminuir el porcentaje de pacientes con secuelas neurológicas

Vertebral infections after spinal puncture are rare and often inadequately documented. Their incidence does not exceed that of spontaneous epidural abscesses and we should therefore be cautious about assuming a causal relation between puncture and an abscess. After analyzing 10 published cases we saw that only half of them reported on aseptic conditions and only 2 patients seem to have had a prior infection. In 3 cases, the abscesses appeared after technically simple punctures whereas half the reports did not even mention the type of puncture. This complication should be considered whenever a patient develops back pain and fever, even if there are no neurological deficits and even after a simple spinal puncture. Given that early diagnosis and treatment have proven effective in improving the survival rate and reducing the rate of neurological sequelae, magnetic resonance images should be ordered urgently so that early treatment can be established

Respuesta de supresión (BSR) en entropía por hipotermia moderada en un paciente con transfusión masiva / Burst suppression entropy response to moderate hypothermia in a patient receiving a massive transfusion

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Enfisema subcutáneo masivo y perimuscular en cirugía laparoscópica de colon / Massive subcutaneous emphysema involving perimuscular tissue in laparoscopic surgery on the colon

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[Non-metabolic application of indirect calorimetry]. / Aplicaciones no metabólicas de la calorimetría indirecta.

INTRODUCTION: The metabolic monitoring of the critical patient by means of indirect calorimetry is a technique that is used more and more often in ICU's. OBJECTIVES: To establish the methodological basis for the application of indirect calorimetry in the ventilatory monitoring of the critical patient. METHODS: 20 critical patients with complete support ventilation, who because of their clinical condition required an increased or decreased ventilatory minute volume, are monitored with indirect calorimetry (Deltatrac). The dead space was calculated (Vd/Vt ratio) using the formula; Vd/Vt = 1 - (0.863 x VeCO2/PaCO2 x Vm). The changes in carbon dioxide exhalation (VeCO2) were measured, and so was the dead space after changing the ventilation parameters, and the stabilization time of both parameters was measured also. RESULTS: The average oxygen use (VO2) was 265 +/- 45 ml/min, the average baseline VeCO2 was 219 +/- 38 ml/min, and the mean baseline PaCO2 was 37.8 +/- 8 mm Hg. The mean initial minute volume (Vm) was 10.8 +/- 3.2 l/min; in 10 patients this increased in 74 +/- 20%, and in the rest it decreased by 42 +/- 7%. The time required to reach the new equilibrium was less when the minute volume increased than if this decreased: 45.6 +/- 10 vs. 74.2 +/- 7 min (p < 0.01) for the VeCO2, and 45.4 +/- 7 vs. 76 +/- 6.8 min (p < 0.01) for the PaCO2. Both the PaCO2 and the VeCO2 reached the new equilibrium in similar times. The Vd/Vt prior to the ventilatory change was 0.5 +/- 0.12 and after the change the ratio was 0.49 +/- 0.1; in patients in whom the Vm decreased, the Vd/Vt also decreased (p < 0.01), but in contrast, when the Vm increased, the dead space did too (p < 0.01). CONCLUSIONS: On one hand indirect calorimetry permits monitoring of the metabolic equilibrium, and on the other hand in can monitor the patient's hemodynamics (Fick method) and finally, as has been show by this study, it allows a monitoring of the ventilatory situation of the critical patient with complete supported ventilation.