Protocolo de donación tras la muerte cardiaca controlada (donante tipo III de Maastricht). Experiencia inicial / Donation protocol following controlled cardiac death (Maastricht type III donation). First experience

OBJETIVO: Presentar la experiencia inicial con la implantación de un programa de donación tras la muerte cardiaca controlada en donantes tipo III de Maastricht. DISEÑO: Estudio retrospectivo, observacional y descriptivo. Ámbito: Unidad de cuidados intensivos de un hospital universitario terciario. PARTICIPANTES: Se evalúan 8 pacientes con enfermedad irreversible en los que se aplica la limitación de las técnicas de soporte vital y se consideran como potenciales donantes de órganos. INTERVENCIONES: Aplicación del protocolo presentado. Variables de interés: Características clínicas de los donantes, tipo de protocolo de donación aplicado, tiempos de isquemia caliente manejados y evolución a corto plazo de los receptores. RESULTADOS: Se incluyeron 8 pacientes. En uno de ellos se suspendió la donación al no fallecer en los 120min siguientes a la extubación terminal. Los 7 restantes fueron donantes renales efectivos. Los tiempos de isquemia caliente estuvieron siempre por debajo de los 23min. Los 14 receptores evolucionaron favorablemente; 7 de ellos presentaron retraso en la función del injerto pero en todos mejoró la función renal. CONCLUSIÓN: La donación tras la muerte cardiaca controlada en pacientes con enfermedad irreversible y catastrófica es una potencial fuente de donantes no considerada en nuestro país hasta el momento actual. Un programa previamente consensuado puede suponer un incremento en el número de órganos a los ya proporcionados por medio de la donación tras la muerte encefálica. Los resultados del trasplante renal en nuestra experiencia han sido buenos y el éxito de este tipo de programas podría extenderse al trasplante hepático y pulmonar

OBJECTIVE: To present our experience with the implementation of a donation protocol following controlled cardiac death (Maastricht type III donation). DESIGN: A retrospective descriptive and observational study was made. SETTING: Intensive Care Unit of a third-level university hospital. PATIENTS: Eight patients in an irreversible state, in which withdrawal of all life support had been agreed, were evaluated as potential donors. INTERVENTIONS: Application of the adopted protocol. Variables of interest: Clinical data of donors, evaluation of a donation protocol following cardiac death, warm ischemia times, and short-term outcome of the recipients. RESULTS: Eight patients were evaluated. In one case donation was not possible because no cardiac arrest developed in the 120minutes after extubation. The 7 remaining patients were effective kidney donors. Warm ischemia times were less than 23minutes in all cases. Although 7 of the 14 recipients suffered delayed graft function, all of them achieved good renal function. CONCLUSION: Donation after cardiac death in patients in an overwhelming and irreversible state represents a potential source of donors not previously considered in this country. The prior development of a consensus-based protocol can help increase the number of organs in combination with those obtained after brain death. In our experience, the results of kidney transplants obtained from donors after cardiac death are good, and the success of these types of protocols could be extended to other organs such as the liver and lungs

[Donation protocol following controlled cardiac death (Maastricht type III donation). First experience]. / Protocolo de donación tras la muerte cardiaca controlada (donante tipo iii de Maastricht). Experiencia inicial.

OBJECTIVE: To present our experience with the implementation of a donation protocol following controlled cardiac death (Maastricht type III donation). DESIGN: A retrospective descriptive and observational study was made. SETTING: Intensive Care Unit of a third-level university hospital. PATIENTS: Eight patients in an irreversible state, in which withdrawal of all life support had been agreed, were evaluated as potential donors. INTERVENTIONS: Application of the adopted protocol. VARIABLES OF INTEREST: Clinical data of donors, evaluation of a donation protocol following cardiac death, warm ischemia times, and short-term outcome of the recipients. RESULTS: Eight patients were evaluated. In one case donation was not possible because no cardiac arrest developed in the 120 minutes after extubation. The 7 remaining patients were effective kidney donors. Warm ischemia times were less than 23 minutes in all cases. Although 7 of the 14 recipients suffered delayed graft function, all of them achieved good renal function. CONCLUSION: Donation after cardiac death in patients in an overwhelming and irreversible state represents a potential source of donors not previously considered in this country. The prior development of a consensus-based protocol can help increase the number of organs in combination with those obtained after brain death. In our experience, the results of kidney transplants obtained from donors after cardiac death are good, and the success of these types of protocols could be extended to other organs such as the liver and lungs.

Tigecycline therapy for infections due to carbapenemase-producing Klebsiella pneumoniae in critically ill patients.

BACKGROUND: The aim of this study was to assess the efficacy of tigecycline in the treatment of infections due to carbapenemase-producing Klebsiella pneumoniae (CPKP) in critically ill patients. METHODS: A retrospective observational study was conducted in critically ill patients receiving different tigecycline doses for severe CPKP infections. We evaluated demographic data, localization and severity of infection, response to therapy, and mortality. RESULTS: Fifteen patients received tigecycline for 16 episodes of CPKP infection. The main infections were pneumonia (31%), urinary tract infection (31%), peritonitis (20%), catheter-related bacteraemia (12%), and meningitis (6%). Most infections were complicated with severe sepsis (44%), septic shock (12%), and/or bacteraemia (19%). The daily maintenance dose of tigecycline was 200 mg in 10 episodes and 100 mg in 6 episodes. The overall 30-day mortality rate was 25%. Univariate analysis showed that mortality was significantly associated (p < 0.01) with mean APACHE II and SOFA scores and the presence of immunosuppression, but not with the tigecycline dose. CONCLUSIONS: Tigecycline appears to be an effective therapy for severe infections due to CPKP in critically ill patients. Mortality is related to the severity of the underlying disease. We observed no benefit from a higher maintenance dose of tigecycline, although the number of patients included in the study was too small to draw any general conclusions in this regard.

Trombolisis en el ictus isquémico agudo en centros sin unidad de ictus: ¿derivación a centro de referencia o tratamiento in situ? / Thrombolysis in acute ischemic stroke in centers lacking a stroke unit: referral to reference center or on-site treatment?

Objetivo: Cuantificar los resultados clínicos de la trombolisis in situ frente a la trombolisis diferida en un hospital de referencia en pacientes con ictus isquémico atendidos en un hospital sin unidad de ictus. Diseño: Análisis de decisiones de valor esperado y simulación de Monte Carlo. Pacientes y ámbito: Simulación basada en un estudio de cohortes (SIT-MOST) y un meta-análisis de ensayos aleatorizados de trombolisis contra placebo en pacientes con ictus isquémico agudo. Intervenciones: Trombolisis in situ frente a la trombolisis diferida en un centro dotado de unidad de ictus. Variables principales: Resultados neurológicos (escala de Rankin modificada) a los 3 meses del ingreso en función de la demora en la aplicación de la trombolisis. Resultados: En las condiciones basales del estudio SIT-MOST (demora inicial de 135min, tiempo de transporte de 60min) el tratamiento in situ fue más efectivo que la derivación a otro hospital (número de pacientes con resultado neurológico favorable de 45,3 frente al 41,3%). En los pacientes atendidos a los 45 minutos, de cada 10 pacientes trasladados se produce un caso adicional con resultado neurológico desfavorable, que se hubiera evitado con el tratamiento trombolítico in situ. En el análisis de Monte Carlo, sesgado en contra del tratamiento in situ mediante una reducción de la efectividad del 30%, el tratamiento in situ fue superior a la derivación de los enfermos en el 77,2% de los casos. Conclusiones: La evidencia disponible no apoya las recomendaciones de la estrategia nacional del ictus y de los diversos planes autonómicos que desaconsejan la realización de trombolisis en hospitales sin unidades de ictus (AU)

Objective: To assess the clinical impact of on-site thrombolysis versus referral to another hospital in patients with ischemic stroke attended in a hospital lacking a stroke unit. Design: Expected value decision analysis and Monte Carlo simulation. Patients and setting: Decision analysis based on a cohort study (SIT-MOST) and a meta-analysis of randomized trials of thrombolysis versus placebo in patients with acute ischemic stroke. Interventions: On-site thrombolysis (in hospitals lacking a stroke unit) versus delayed thrombolysis in a reference hospital. Main outcomes: Neurological outcome (modified Rankin scale) three months after admission according to the delay in the administration of thrombolysis. Results: At baseline (initial delay of 135min, travel time 60minutes), on-site treatment was more effective than referral to another hospital (number of patients with favorable neurological outcome 45.3% versus 41.3%). In patients seen within 45minutes of the onset of symptoms, for every 10 patients transferred there was an additional case with an unfavorable neurological outcome that could have been avoided with on-site thrombolysis. In the Monte Carlo analysis, biased against on-site treatment by a reduction in effectiveness of 30%, on-site treatment was superior to patient referral in 77.2% of the cases. Conclusions: The available evidence does not support the recommendations of the national stroke strategy or some regional plans that discourage the administration of thrombolysis in hospitals without stroke units (AU)

[Thrombolysis in acute ischemic stroke in centers lacking a stroke unit: referral to reference center or on-site treatment?]. / Trombolisis en el ictus isquémico agudo en centros sin unidad de ictus: ¿derivación a centro de referencia o tratamiento in situ?

OBJECTIVE: To assess the clinical impact of on-site thrombolysis versus referral to another hospital in patients with ischemic stroke attended in a hospital lacking a stroke unit. DESIGN: Expected value decision analysis and Monte Carlo simulation. PATIENTS AND SETTING: Decision analysis based on a cohort study (SIT-MOST) and a meta-analysis of randomized trials of thrombolysis versus placebo in patients with acute ischemic stroke. INTERVENTIONS: On-site thrombolysis (in hospitals lacking a stroke unit) versus delayed thrombolysis in a reference hospital. MAIN OUTCOMES: Neurological outcome (modified Rankin scale) three months after admission according to the delay in the administration of thrombolysis. RESULTS: At baseline (initial delay of 135 min, travel time 60 minutes), on-site treatment was more effective than referral to another hospital (number of patients with favorable neurological outcome 45.3% versus 41.3%). In patients seen within 45 minutes of the onset of symptoms, for every 10 patients transferred there was an additional case with an unfavorable neurological outcome that could have been avoided with on-site thrombolysis. In the Monte Carlo analysis, biased against on-site treatment by a reduction in effectiveness of 30%, on-site treatment was superior to patient referral in 77.2% of the cases. CONCLUSIONS: The available evidence does not support the recommendations of the national stroke strategy or some regional plans that discourage the administration of thrombolysis in hospitals without stroke units.

Medicina de cuidados intensivos / Intensive care medicine

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[The application of impedance analysis to the study of body composition]. / La aplicación del análisis de impedancia al estudio de la composición corporal.

We have reviewed the physical theory of body composition assessment using bioelectrical impedance analysis. We discuss the measurement reproducibility, the application to the estimation of total body water, extracellular water, nutritional assessment and the measurement of total body fat. We also comment the application to the study of body composition in children, other physiological and pathological situations and the utility in epidemiological studies.