Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery. / Impacto en el manejo diagnóstico/terapéutico de la ecocardiografía básica dirigida a objetivos concretos en una UCI de cirugía cardíaca.

OBJECTIVE: Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients. DESIGN: Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis. RESULTS: We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes. CONCLUSIONS: Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study.

OBJECTIVE: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN: Prospective multicenter study. SETTING: Eleven ICUs. PATIENTS: All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery.

BACKGROUND: Transthoracic echocardiography can significantly change the management of many critical patients, and is being incorporated into many Intensive Care Units (ICU). Very few studies have examined the feasibility and impact of intensivists performing basic transthoracic echocardiography upon the management of critical patients after cardiac surgery. The present study therefore evaluates the quality of acquisition and accuracy of intensivist interpretation of basic transthoracic echocardiograms in the postoperative period of heart surgery. METHODS: Over an 8-month period we prospectively studied 148 patients within 24h after admission to a university hospital ICU following heart surgery. We performed basic transthoracic echocardiography to evaluate ventricular function, pericardial effusion, hypovolemia and mitral regurgitation. Cohen's Kappa was used to compare transthoracic echocardiograms obtained by intensivists with basic versus advanced training. Concordance on image acquisition and interpretation was evaluated. RESULTS: We analyzed data of adequate transthoracic echocardiograms in 148 patients (92.5%). Apical four-chamber view and advanced trainees obtained better quality images. Concordance was good for right and left ventricular function (kappa=0.7±0.14 and 0.87±0.05, respectively), and moderate for the remaining parameters. Interpretation concordance between basic and advanced training intensivists was good (kappa=0.73±0.05). CONCLUSIONS: Intensivists with basic training in echocardiography are capable of performing and interpreting echocardiograms in most patients during the postoperative period of heart surgery.

[Clinical course and prognostic factors in lupus nephropathy]. / Evolución y factores pronósticos de la nefropatía lúpica.

BACKGROUND: The present study was designed to know the clinical course of lupus nephritis and the risk factors associated with the development of end stage renal disease. METHODS: This a retrospective study performed in a cohort of 154 patients with biopsy proven lupus nephritis that were seen in our hospital between 1984 and 1990. The clinical records of all patients were reviewed in order to collect the following information at the time of the biopsy: age, sex, number and type of lupus criteria according with the American College of Reumathology, mean arterial pressure, serum creatinine, BUN, and albumin, as well as urinary protein excretion. The follow up was registered from the day the biopsy was performed to one of the following end points: end stage renal disease (defined as requirement of chronic dialysis), death or the end of study. All biopsies were analyzed by light microscopy to obtain the hystological subtype of lupus nephritis (WHO classification) and when type IV was diagnosed, the activity and chronicity indexes were also assessed. Kaplan-Meier survival tables were constructed. The association of clinical and laboratory variables with the development of end stage renal disease was obtained by log rank analysis. Variables obtained as significant were used to evaluate their individual impact using either the Cox multivariate proportional hazard method. RESULTS: Follow up was complete in 144 patients with a follow up time of 68 +/- 38 months. Ninety three patients were female with mean age of 28 +/- 9 years. At the time of the biopsy, renal manifestations had been present for 35 +/- 38 months and the number of lupus criteria per patient were 4 +/- 1. The clinical picture at the time of the biopsy was: nephrotic syndrome in 60%, non nephrotic proteinuria in 40%, and nephritic syndrome in only 2%. The hystological type of lupus nephritis was: I in 2%, II in 8%, III in 6%, IV in 71% and V in 11%. At the end of the study 28 patients developed end stage renal disease. For the whole group the survival of renal function was 85% at 70 months and 70% at 140 months. All, but one patient that developed end stage renal disease exhibited type IV nephropathy. In this subpopulation the mean activity and chronicity indexes were 8.5 +/- 3.5 and 3.1 +/- 2.4, respectively. By multivariate analysis the strongest predictors of end stage renal disease were the serum creatinine at the time of the biopsy, chronicity index, and age. The higher the serum creatinine and chronicity index at the time of biopsy, the higher the probability of developing end stage renal disease. CONCLUSIONS: We conclude that the clinical course of lupus nephritis in our population is similar to that seen in other series. The variables indicating advanced renal disease, such as high serum creatinine and chronicity index, were the strongest predictors of end stage renal disease.

Endoscopic evolution of laryngeal injuries caused by translaryngeal intubation.

Despite improvements in tube design and materials, the longer survival rates of critically ill patients make laryngeal and tracheal lesions still common following prolonged translaryngeal intubation. The time of intubation is almost the only factor employed in deciding whether or not tracheotomy has to be performed. Some patients will not develop laryngeal lesions afer long intubation periods, whereas some already have clinical symptoms after short periods of time. If the conditions of the larynx and trachea could be assessed before irreversible complications take place, then timing of tracheotomy could be individualized to avoid laryngeal stenosis as well as unnecessary tracheostomies. We present the preliminary results of an endoscopic study of the early laryngeal changes that take place during translaryngeal intubation. The method of exploration is explained and tissue changes seen and their evolution after extubation are described, emphasizing those that could have a predictive value.