Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea / Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)

IntroducciónLas técnicas de depuración extracorpórea (TCDE) gestionan elevados volúmenes de intercambio de fluidos y precisa control exhaustivo de su seguridad.ObjetivoDetectar riesgos en TCDE y determinar su frecuencia por paciente.Material y métodoEstudio observacional retrospectivo. Criterios de inclusión: pacientes ingresados desde enero a diciembre de 2009 con TCDE en la Unidad de Cuidados Intensivos (UCI) Polivalente del Hospital 12 de Octubre. Identificamos previamente diez riesgos detectables en historias clínicas. Analizamos variables demográficas y del tratamiento. Las variables cuantitativas se expresan como media±desviación estándar y cualitativas, como frecuencias absolutas y relativas. Análisis: SPSS 15.0®.ResultadosSe incluyó a 54 pacientes (11,7%) con media de edad de 59,78±14,8 años; 42 (77,8%) eran varones. En el 81,4% la indicación fue fracaso renal agudo. Se trató al 80,3% con hemodiafiltración. La media de TCDE fue de 112,9±139,9 h, con una mediana [intervalo intercuartílico] de 2 [0-31] filtros por paciente. La frecuencia de riesgo/paciente fue: el 100% de los pacientes sin monitorización de Mg y P, y el 3,7% (n=2) urea; en 16 (29,6%) se produjo coagulación del circuito antes de 24 h y en 25 (46,3%) no se pudo devolver sangre; en 14 (29,3%) faltaba siempre pauta escrita en la orden de tratamiento; en gráfica del paciente no se reflejó las dosis en 2 (3,7%); en 3 pacientes (5,6%) con coagulopatía se pautó anticoagulante en el circuito; en 1 (1,9%) se evidenció sangrado y en 10 (18,5%), hipotermia leve (35-32°C).ConclusionesSe precisa monitorización protocolizada de Mg y P. Se debe pautar la terapia en el tratamiento médico. Se precisa optimizar la técnica para prolongar su duración y evitar pérdidas hemáticas (AU)

IntroductionContinuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required.ObjectiveTo detect the risks of CTED and to determine its frequency per patient.Material and methodsAn observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. Analysis: SPSS 15.0®.ResultsA total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C).ConclusionsA standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses (AU)

[Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)]. / Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea.

INTRODUCTION: Continuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required. OBJECTIVE: To detect the risks of CTED and to determine its frequency per patient. MATERIAL AND METHODS: An observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. ANALYSIS: SPSS 15.0(®). RESULTS: A total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24 hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C). CONCLUSIONS: A standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses.

Evidencias científicas de electroterapia y termoterapia en lumbalgia y lumbociatalgia / Scientific evidence of electrotherapy and thermotherapy in low back pain and sciatica

El tratamiento de la lumbalgia y lumbociatalgia suele ser multidisciplinar y es común que incluya terapia física. Dentro de ésta y como medida analgésica se emplea la electroterapia. Sin embargo, no existe una pauta de actuación bien definida respecto a qué aparatos utilizar y con qué parámetros. Propósito. Buscar la evidencia científica para la electroterapia que se emplea con mayor frecuencia en el tratamiento de estas patologías y proponer pautas de tratamiento con la mayor eficacia conocida. Método. Se buscaron los estudios más relevantes (aleatorios, con grupo placebo y/o control y a ciego) en las bases de datos PEDro y MEDLINE, desde el año 1983 hasta 2003 inclusive. Resultados. La Estimulación Eléctrica Trancutánea (TENS), a pesar de su efecto placebo, demuestra ser eficaz a corto-medio plazo cuando se emplea con una frecuencia elevada (100 Hz) y un tiempo de pulso de 125 μseg. Los ultrasonidos son eficaces en patología discal al utilizarlos durante 10 min con una intensidad entre 1-2 W/cm2. El láser de arseniuro de galio demuestra su efectividad cuando se aplica con dosis de 4 J/cm2. La técnica que obtiene mejores reducciones del dolor a corto plazo, tanto en la lumbalgia como en la ciatalgia, es la Terapia de Neouromodulación PercutáneaEl tratamiento de la lumbalgia y lumbociatalgia suele ser multidisciplinar y es común que incluya terapia física. Dentro de ésta y como medida analgésica se emplea la electroterapia. Sin embargo, no existe una pauta de actuación bien definida respecto a qué aparatos utilizar y con qué parámetros. Propósito. Buscar la evidencia científica para la electroterapia que se emplea con mayor frecuencia en el tratamiento de estas patologías y proponer pautas de tratamiento con la mayor eficacia conocida. Método. Se buscaron los estudios más relevantes (aleatorios, con grupo placebo y/o control y a ciego) en las bases de datos PEDro y MEDLINE, desde el año 1983 hasta 2003 inclusive. Resultados. La Estimulación Eléctrica Trancutánea (TENS), a pesar de su efecto placebo, demuestra ser eficaz a corto-medio plazo cuando se emplea con una frecuencia elevada (100 Hz) y un tiempo de pulso de 125 μseg. Los ultrasonidos son eficaces en patología discal al utilizarlos durante 10 min con una intensidad entre 1-2 W/cm2. El láser de arseniuro de galio demuestra su efectividad cuando se aplica con dosis de 4 J/cm2. La técnica que obtiene mejores reducciones del dolor a corto plazo, tanto en la lumbalgia como en la ciatalgia, es la Terapia de Neouromodulación Percutánea (PNT o PENS), que demuestra ser eficaz cuando se utiliza una frecuencia alternante de 15/30 Hz, un tiempo de pulso entre 0,5-0,7 mseg, intensidad máxima sin contracción muscular y una duración de 30 minutos por sesión. Conclusiones. Existe evidencia científica para incluir la electroterapia en el tratamiento de la lumbalgia y ciatalgia

The treatment of low back pain and sciatica is usually multidisciplinary and it often includes physical therapy. Electrotherapy is used as part of the latter as an analgesic measure. However, there is no well defined therapy regimen with regards to which equipment and parameters to use. Purpose. To find scientific evidence for electrotherapy, which is used more and more often in the treatment of these pathologies and to propose treatment regimens with the best know efficacy. Methods. We searched for the most relevant studies (randomized, with a placebo and/or control group and blind) in the PEDro and MEDLINE databases from 1983 to 2003 inclusive. Results. TENS, despite its placebo effect, proves to be effective in the short-medium term when it is used with a high frequency (100 Hz) and a pulse width of 125 μs. Ultrasound is effective in disc disease when used for 10 minutes with an intensity between 1-2 W/cm2. The gallium arsenide laser proves its effectiveness in chronic low back pain when it is applied with a dose of 4 J/cm2. The technique with the best short-term pain relief results in both low back pain and sciatica is Percutaneous Neuromodulation Therapy (PNT or PENS), which proves to be effective when it is used with an alternating frequency of 15/30 Hz, a pulse width between 0.5-0.7 ms, maximum intensity without muscular contraction and an application of 30 minutes at each treatment session. Conclusions. There is scientific evidence for including electrotherapy in the treatment of low back pain and sciatica

Latent Haemophilus influenzae pneumonia in patients infected with HIV.

Pneumonia caused by common pyogenic bacteria occurs frequently in HIV-infected patients. Its clinical presentation has been described as being similar to that seen in non-immunosuppressed hosts but clearly different to that of opportunistic pneumonias. An atypical presentation has rarely been seen. In a 10-month period, we saw 12 HIV-infected patients who presented with Haemophilus influenzae pneumonia which was clinically and radiologically indistinguishable from Pneumocystis carinii pneumonia. Ten of the patients were intravenous drug users and were in different stages of HIV disease. The clinical picture was characterized by a prolonged course (median 4 weeks), non-productive cough, dyspnoea, and absence of findings usually present in bacterial pneumonia. Laboratory data frequently showed absence of leukocytosis, increased lactate dehydrogenase levels, hypoxaemia, and decreased CD4+ cell counts. All presented with interstitial or mixed bilateral infiltrates. Resistance to ampicillin and trimethoprim-sulphamethoxazole were each found in seven cases. Eleven patients were cured with antibiotic therapy, although five relapsed. H. influenzae pneumonia should be considered in HIV-infected patients who present with pulmonary symptoms and bilateral infiltrates of subacute or chronic onset. Clinical resolution of pneumonia is the usual outcome, but recurrences of infection are frequent.

[Monoclonal IgG lambda paraprotein, Fanconi's syndrome of the adult, and osteomalacia (author's transl)]. / Paraproteína monoclonal IgG lambda, síndrome de Fanconi del adulto y osteomalacia.

The case here reported of 72 year-old female with osteomalacia in whom an adult's Fanconi's syndrome with distal tubular involvement and a monoclonal IgG-lambda paraprotein were discovered. There was urinary excretion of lambda light chains without evidence of myeloma or amyloidosis. Such apparently unrelated entities might be subject to an unitary pathophysiological approach: the nephrotoxicity of light chains could cause a Fanconi's syndrome, which in turn would give rise to osteomalacia through phosphate depletion. It is noteworthy that in this patient the urinary excretion of light chains was of the lambda type, in contrast to similar cases described in the literature which presented mostly kappa chains. The likelihood of this patient developing myeloma or amyloidosis at a later stage is discussed.