Análisis retrospectivo sobre la extubación en pacientes con patología neurológica aguda / Retrospective analysis on the extubation in patients with acute neurological pathology

Objetivo: Evaluar la idoneidad de la prueba de respiración espontánea para predecir el fracaso de la extubación de pacientes neurológicos y determinar los factores predictivos de fracaso. Diseño: Casos y controles. De enero de 2001 a diciembre de 2010. Ámbito: Unidad de Cuidados Intensivos. Pacientes: Enfermos neurológicos agudos sometidos a ventilación mecánica y posterior extubación. Se excluyeron: pacientes con cirugías neurológicas programadas, con patología neuromuscular, lesión medular, traqueotomía, politraumatismos con predominio de afectación del resto de los sistemas sobre el neurológico, aquellos que murieron en la Unidad de Cuidados Intensivos o que fueron trasladados. Variables de interés: Tasa de fracaso, infección intrahospitalaria, necesidad de traqueotomía, duración de la ventilación mecánica, estancia en la Unidad de Cuidados Intensivos y en el hospital, mortalidad en esta Unidad, en el hospital y a los 90 días, y factores asociados al fracaso. Resultados: De 479 pacientes, 208 fueron sometidos a prueba de respiración espontánea y posterior extubación. Cincuenta y cuatro (26%) fracasaron, la tasa de complicaciones, la estancia, la duración de la ventilación mecánica y la mortalidad fueron mayores que en el grupo de éxito. Los pacientes con accidente cerebrovascular [OR 4,256 (IC95% 1,442-12,561), p = 0,009] y necesidad de aspiraciones frecuentes [OR 5,699 (IC95% 1,863-17,432), p = 0,002] son más propensos al fracaso [ROC 0,73 (IC95% 0,628-0,840)]. Conclusiones: Los pacientes neurológicos presentan una elevada tasa de fracaso de la extubación con numerosas complicaciones asociadas y muerte. La prueba de respiración espontánea no predijo el éxito de la extubación. Los pacientes con accidente cerebrovascular y necesidad de aspiraciones frecuentes de secreciones se verían abocados a un mayor fracaso de extubación.(AU)

Objective: To assess the adequacy of the spontaneous breathing test to predict extubation failure in neurological patients undergoing mechanical ventilation and to determine factors associated with extubation failure. Design: Case-control study. Between January 2001 and December 2010. Setting: Intensive Care Unit. Patients: Acute neurological patients who underwent mechanical ventilation and were subsequently extubated. Patients with scheduled neurosurgery intervention, neuromuscular disease, spinal cord injury, tracheotomy, multiple trauma with less neurological damage than in other systems, those who died in the Intensive Care Unit or in hospital or those transferred to other hospital, were excluded. Variables of interest: Extubation failure rate, nosocomial infection, need for tracheostomy, duration of mechanical ventilation, ICU and hospital stay, mortality in the ICU or hospital, and at day 90, as well as failure-related factors. Results: Two-hundred and eight patients underwent spontaneous breathing trial, and were subsequently extubated. Fifty-four (26%) patients failed. Patients who failed extubation had a higher complication rate, received mechanical ventilation for more days, their hospitalization was longer, and the mortality rate was higher than in the success group. Patients with stroke [OR 4.256 (95%CI, 1.442-12.561), p=0.009] and those who required a greater number of aspirations during weaning [OR 5.699 (95%CI, 1.863-17.432), p=0.002] were susceptible to extubation failure [ROC curve 0.73 (0.628-0.840)]. Conclusion: Extubation failure in neurological patients is common and frequently associated with severe complications. The spontaneous breathing trial does not predict a successful extubation. Patients with stroke and those who need frequent aspiration of secretions would be doomed to further failure of extubation(AU)

Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI / Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU

Detectar posibles razones de la mortalidad de los pacientes críticos trasladados desde la UCI a las plantas del hospital y analizar las potenciales causas atribuibles de esta mortalidad. Diseño Estudio observacional de datos prospectivos analizados retrospectivamente. Muestra Cohorte de 5.328 pacientes ingresados consecutivamente en nuestro SMI cuya evolución se sigue hasta el fallecimiento o el alta hospitalaria. Período Desde enero de 2006 a diciembre de 2009. Método Análisis de significación diferencial de datos epidemiológicos, clínico-asistenciales, de estimación de riesgo de muerte, de coincidencia de diagnóstico de causa de ingreso en UCI y de causa de fallecimiento y de incidencia de limitación de esfuerzo asistencial. Se consideró alta inadecuada de UCI si la muerte acontecía antes de las 48h del traslado, sin limitación de esfuerzo asistencial.ResultadosFallecieron 907 pacientes (tasa estandarizada de 0,9; IC del 95%, 0,87-0,93) de los que 202 fallecieron tras el alta del SMI (el 3,8% de la población total y el 22,3% de los fallecidos); la estancia en planta post-UCI fue de 12,4±17,9 días. No se detectaron diferencias significativas entre los fallecidos en UCI o tras la estancia en UCI respecto a complicaciones infectivas aparecidas tras el ingreso. Tampoco los reingresados en UCI tras el pase a planta presentaron una mayor mortalidad. Se comprueba que la causa de muerte en planta no es significativamente coincidente con la causa de ingreso en UCI. Discusión Cierta mortalidad de pacientes críticos tras el traslado desde UCI es un hecho habitual. Nuestros datos no permiten atribuir esta mortalidad a deficiencias asistenciales (altas inadecuadas o disminución de asistencia en planta). Las razones para esta mortalidad tienen una explicación variada y variable, y en su mayoría corresponden a evolución del paciente diferente de la previsible tras el traslado desde el SMI (AU)

Objective: To detect possible reasons for mortality of critical patients transferred from the ICUto the hospital wards and to analyze the possible attributable causes for such mortality.Design: An observational study of prospectively collected data, analyzed retrospectively.Population: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolutionwas followed up to hospital discharge or death. Period: From January 2006 to December 2009. Method: An analysis was made of differential significance of epidemiological, clinical-care,death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, withoutlimitation of care effort. Results: A total of 907 patients died (SMR = 0.9; 95% CI, 0.87-0.93), 202 of whom died afterICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of staybeing 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greatermortality was also not found in those re-admitted to the ICU after having been transferred tothe ward. It was verified that the cause of death in the ward did not significantly coincide withthe cause of admission to the ICU.Discussion: Some mortality after ICU discharge is to be expected. Our data do not allow usto attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceasedcare in the wards). The reasons for this mortality have a varied and variable explanation. Itmostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU (AU)

[Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU]. / Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI.

OBJECTIVE: To detect possible reasons for mortality of critical patients transferred from the ICU to the hospital wards and to analyze the possible attributable causes for such mortality. DESIGN: An observational study of prospectively collected data, analyzed retrospectively. POPULATION: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolution was followed up to hospital discharge or death. PERIOD: From January 2006 to December 2009. METHOD: An analysis was made of differential significance of epidemiological, clinical-care, death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, without limitation of care effort. RESULTS: A total of 907 patients died (SMR=0.9; 95% CI, 0.87-0.93), 202 of whom died after ICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of stay being 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greater mortality was also not found in those re-admitted to the ICU after having been transferred to the ward. It was verified that the cause of death in the ward did not significantly coincide with the cause of admission to the ICU. DISCUSSION: Some mortality after ICU discharge is to be expected. Our data do not allow us to attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceased care in the wards). The reasons for this mortality have a varied and variable explanation. It mostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU.

[Electrocardiographic disorders associated to recent onset epilepsy]. / Trastornos electrocardiográficos asociados a epilepsia de reciente comienzo.

INTRODUCTION: Patients who suffer seizures sometimes have electrocardiographic disorders during both the seizure and the post-critical period. The incidence of sudden death in epileptic patients (SUDEP) is greater than that observed in non-epileptic patients, there being evidence of respiratory disorders, cardiac arrhythmias, encephalic involvement and coronary ischemia during the seizures. This coronary ischemia has been mainly described in patients with drug refractory epilepsy, it being quite rare in patients without background of refractory seizures. During the seizure and in the post-critical period, changes have also been described in the ST segment. This suggests that the stimulation of the autonomic system may create the adequate substrate to cause myocardial ischemia. In this situation, ventricular arrhythmias and serious myocardial dysfunction may be observed. Besides the ischemia, on other occasions, there are alterations in the heart rhythm, it being possible to observe different effects and arrhythmias in the same patient. CLINICAL CASE: We present the case of a 50 year old male in whom electrocardiographic alterations with depression of the ST segment, without arrhythmias, were observed immediately after his first seizures. CONCLUSION: In some cases, cardiac alterations previously unknown in epileptic patients could explain the unexpected deaths of epileptics in SUDEP diagnosed cases.

[Lowered incidence of post-lumbar puncture headache following the application of the second edition of the International Headache Society classification]. / Disminución en la incidencia de la cefalea pospunción lumbar tras la aplicación de la segunda edición de la Sociedad Internacional de Cefaleas.

INTRODUCTION: In 1988 the International Headache Society (IHS) published the 1st edition of its headache classification and the 2nd edition was completed in 2003. AIM. To determine whether there exist changes in the incidence of post-lumbar puncture headache depending on the edition of the IHS classification. PATIENTS AND METHODS: Between 2002 and 2003 data was gathered prospectively for 78 patients who were submitted to a diagnostic lumbar puncture, 40 obstetric spinal anaesthesias and 516 non-obstetric spinal anaesthesias. The 1st edition was used and, after the appearance of the 2nd edition, the cases were recoded. RESULTS: With the 1st edition, there were 31 out of 78 cases (39.7%) of post-puncture headache in diagnostic punctures, and when the 2nd edition was used, the number dropped to 10 cases (12.8%). The incidence of headache among patients who had undergone obstetric spinal anaesthesia was six cases out of a total of 40 (15%) using the 1st edition, and four cases with the 2nd edition (10%). The incidence of headache among patients after non-obstetric spinal anaesthesia was 80 cases out of a total of 516 (15.5%) when the 1st edition was utilised and 25 cases with the 2nd edition (4.85%). CONCLUSIONS: To compare the incidences of post-lumbar puncture headaches obtained by diverse observers we need to know which edition was used, since there are considerable differences between the results obtained using one edition or the other. The main reason accounting for the discrepancy between the two editions is the compulsory association of some accompanying sign, since this was not a necessary criterion in the 1st edition but it is included in the 2nd.