Síndrome de distrés respiratorio agudo: revisión a propósito de la definición de Berlín / Acute respiratory distress syndrome: A review of the Berlin definition

El síndrome de distrés respiratorio agudo (SDRA) constituye una entidad de etiología muy diversa. La ausencia de definición universal se ha traducido en una serie de problemas a la hora de realizar un diagnóstico exhaustivo. Por ello, en los estudios publicados hasta el momento, la incidencia del SDRA y lesión pulmonar aguda (LPA) presentan cifras muy variables. La definición de la Conferencia Americana-Europea de Consenso se ha aplicado desde su publicación en 1994 después de 18 años, la Sociedad Europea de Medicina Intensiva convocó en 2011 a un equipo internacional de expertos en Berlín, para revisar la definición de SDRA. El objetivo de la definición de Berlín no es emplearla como pronóstico, sino mejorar la coherencia entre la investigación y la práctica clínica (AU)

Acute Respiratory Distress Syndrome (ARDS) is due to many causes. The absence of a universal definition up until now has led to a series of practical problems for a definitive diagnosis. The incidences of ARDS and Acute Lung Injury (ALI) vary widely in the current literature. The American-European Consensus Conference definition has been applied since its publication in 1994 and has helped to improve knowledge about ARDS. However, 18 years later, in 2011, the European Intensive Medicine Society, requested a team of international experts to meet in Berlin to review the ARDS definition. The purpose of the Berlin definition is not to use it as a prognostic tool, but to improve coherence between research and clinical practice

[Acute respiratory distress syndrome: a review of the Berlin definition]. / Síndrome de distrés respiratorio agudo: revisión a propósito de la definición de Berlín.

Acute Respiratory Distress Syndrome (ARDS) is due to many causes. The absence of a universal definition up until now has led to a series of practical problems for a definitive diagnosis. The incidences of ARDS and Acute Lung Injury (ALI) vary widely in the current literature. The American-European Consensus Conference definition has been applied since its publication in 1994 and has helped to improve knowledge about ARDS. However, 18 years later, in 2011, the European Intensive Medicine Society, requested a team of international experts to meet in Berlin to review the ARDS definition. The purpose of the Berlin definition is not to use it as a prognostic tool, but to improve coherence between research and clinical practice.

Listeria monocytogenes y Herpes simplex tipo 1, asociados en un episodio de meningoencefalitis en un paciente inmunodeprimido / Listeria monocytogenes and Herpes simplex type 1, associated in a meningoencephalitis episode in an immunodepressed patient

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[Perioperative fluid therapy]. / Fluidoterapia perioperatoria.

Physiologic balance between fluids and electrolytes should remain stable during the perioperative period. Gaps in our understanding of how this balance is maintained has given rise to inappropriate management practices. Both failure to replace lost fluids and the infusion of excessive amounts can lead to serious consequences for the patient. There is currently renewed interest in studying the best use of fluids and/or blood products during and after surgery. This update of perioperative fluid therapy is based on a review of indexed literature retrieved by means of a PubMed search for the period of January 1999 through December 2009.

[Myocarditis in the differential diagnosis of acute coronary syndrome]. / Miocarditis como diagnóstico diferencial del síndrome coronario agudo.

A 69-year-old man with no remarkable medical history was admitted to the intensive care unit in septic shock due to severe community-acquired pneumonia. Twelve hours later he developed electrocardiographic abnormalities with ST elevation in leads II, III, aVF, V5, and V6 in the absence of chest pain and the presence of dyspnea, agitation, and hypertension. Serial measurements of cardiac enzymes were also elevated. Acute coronary syndrome was suspected. A cardiac ultrasound revealed left ventricular dilation with akinesia and systolic dysfunction (ejection fraction, 40%). Emergency catheterization revealed normal coronary arteries, suggesting a probable diagnosis of acute myocarditis. From the fourth day, the patient was progressing favorably. Findings in a follow-up ultrasound were consistent with the onset of dilated myocardiopathy, and angiotensin converting enzyme inhibitors were prescribed. All serology and microbiological studies were negative. Fifteen days after admission the patient was discharged to home after clinical, radiologic and analytic recovery.

Miocarditis como diagnóstico diferencial del síndrome coronario agudo / Myocarditis in the differential diagnosis of acute coronary syndrome

Presentamos el caso de un varón de 69 años, previamentesano, que ingresó en la Unidad de Reanimaciónde nuestro hospital por un cuadro de shock séptico porneumonía grave adquirida en la comunidad.A las 12 horas del ingreso presentó un cuadro de alteracioneselectrocardiográficas con elevación del ST en lasderivaciones II, III, aVF, V5 y V6, sin clínica de dolor torácicopero con aumento de la disnea, sensación de angustiay aumento de las cifras de TA. Las determinaciones seriadasde enzimas cardiacos resultaron también elevadas.Con la sospecha de síndrome coronario agudo se realizóun ecocardiograma que objetivó dilatación del VIcon acinesia y disfunción sistólica global (FE 40%).Dado el resultado se practicó un cateterismo urgente queinformó de arterias coronarias normales, sugiriendocomo probable diagnóstico una miocarditis aguda.A partir del cuarto día evolucionó favorablemente,siendo objetivado en el ecocardiograma de controlhallazgos compatibles con el inicio de una miocardiopatíadilatada instaurándose tratamiento con IECA. Todoslos estudios microbiológicos y las serologías realizadasfueron negativos.El paciente fue dado de alta domiciliaria a los 15 díasobjetivándose recuperación clínica, radiológica y analítica

A 69-year-old man with no remarkable medical historywas admitted to the intensive care unit in septicshock due to severe community-acquired pneumonia.Twelve hours later he developed electrocardiographicabnormalities with ST elevation in leads II, III, aVF,V5, and V6 in the absence of chest pain and the presenceof dyspnea, agitation, and hypertension. Serialmeasurements of cardiac enzymes were also elevated.Acute coronary syndrome was suspected. A cardiacultrasound revealed left ventricular dilation with akinesiaand systolic dysfunction (ejection fraction, 40%).Emergency catheterization revealed normal coronaryarteries, suggesting a probable diagnosis of acute myocarditis.From the fourth day, the patient was progressingfavorably. Findings in a follow-up ultrasound wereconsistent with the onset of dilated myocardiopathy, andangiotensin converting enzyme inhibitors were prescribed.All serology and microbiological studies were negative.Fifteen days after admission the patient was dischargedto home after clinical, radiologic and analyticrecovery

Intento autolítico con superwarfarinas / Attempted autolysis with super warfain

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Hematoma subaracnoideo tras punción lumbar diagnóstica / Subarachnoid hematoma after diagnostic lumbar puncture

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[Growth charts for the Spanish population with neurofibromatosis type 1]. / Gráficos de crecimiento de la población española con neurofibromatosis tipo 1.

OBJECTIVE: To make the charts of stature and head circumference of Spanish pediatric patients affected with neurofibromatosis type 1 (NF1), to compare them with the ones from a healthy population and to review the possible causes of its alterations. PATIENTS AND METHODS: We obtained the data from 251 Spanish patients (122 women and 129 men) with NF1 seen in seven hospitals between the years 2000 and 2002, with ages between 1 month and 18 years old. The calculation of the 50th centile or median was done using the method of mobile variables, and the 3rd and 97th centiles where calculated from this median. RESULTS: Girls with NF1 have a shorter stature than the healthy ones, which becomes evident after 10 years of age. We have not found differences in the stature between boys with the disease and those without it. In regards to head circumference, in boys and girls we have observed that it is bigger throughout life in patients affected with NF1, and that the 50th centile of healthy people correlates with the 3rd centile of those affected, the 97th centile of the healthy ones with the 50th centile of those affected, being the 3rd centile of the healthy people well below the 3rd centile of the affected ones, and the 97th centile of the affected ones well above the 97th of the healthy people. CONCLUSIONS: The short stature in postpuberal girls and the macrocephaly in both sexes at all ages, are primary characteristics in the NF1 and they are not usually related with other alterations, although they are not specific for this illness.

Antibiotic resistance of Salmonella spp. from animal sources in Spain in 1996 and 2000.

Emergence of resistant and multiresistant bacteria has become an important worldwide sanitary problem. International agencies recommend improving resistance surveillance studies in not only human but also animal origin strains. Because of its ubiquitous characteristics and zoonotic agent consideration, Salmonella spp. can be used as a good indicator microorganism for resistance surveillance studies. Salmonella spp. strains from animal sources isolated in 1996 (107) and 2000 (474) in Spain were tested against 12 different antimicrobials agents, using the disc diffusion method. Results were interpreted following the NCCLS criteria. Data showed that Salmonella spp. strains (61.7% in 1996 and 81.5% in 2000) were resistant to at least one antibiotic. Pig-related strains were considerably more resistant than strains from other sources. Enteritidis serotype was less resistant than other serotypes, except for ampicillin in 1996 (50% resistant) and nalidixic acid in 2000 (65.1% resistant). An emergent monophasic serotype, 4,5,12:i:-, first detected in 1997 in Spain was 100% resistant and 90% multiresistant. Typhimurium serotype was the most common Salmonella serotype from animal sources in both years. It was widely distributed among animals and was among the serotypes with a higher degree of resistance. The ampicillin, chloramphenicol, sulfonamides, streptomycin, and tetracycline resistance pattern, commonly associated with Salmonella serotype Typhimurium DT 104, had spread among other Typhimurium phage types and other Salmonella serotypes. Salmonella spp. strains isolated from feeding stuffs were considerably more susceptible than animal source strains, suggesting that the high Salmonella spp. resistance percentage was probably due to the use of antibiotics in animal farms rather than the consumption of contaminated feeding stuffs.

Antimicrobial resistance in salmonellae from humans, food and animals in Spain in 1998.

We studied 1710 Salmonella: spp. isolates from human (1051), food (421) and animal (238) sources. They were tested by the disc diffusion method for susceptibility to 12 different antimicrobial agents. The incidence of resistance and multiple resistance (MR) among the salmonella strains of different origins, the relationship between their most frequent serotypes and phage types (PTs) and their antimicrobial resistance patterns were determined. In general, the incidence of resistance and MR was significantly higher in animal isolates than in human and food isolates (P < 0.05). Resistance to each individual drug among the human isolates and food isolates was very similar, with resistance to ampicillin, tetracycline, streptomycin and sulphonamides most frequently observed. MR has remained uncommon in Salmonella enteritidis. Nevertheless, 90% of PT6A of the human isolates and 100% of the food isolates were ampicillin resistant and 80 and 60%, respectively, of the PT1 isolates were nalidixic acid resistant. Salmonella typhimurium was the most multiresistant serotype in the three sample populations and ten different patterns of MR were seen. Almost 100% of the Salmonella hadar isolates, from human and food sources, were resistant. We recommend restriction of the use of antibiotics in veterinary medicine in order to reduce the selection and spread of multiresistant strains.

[Infection and sepsis in resuscitation]. / Infección y sepsis en reanimación.

Perhaps no area of medicine has advanced as dramatically and rapidly as the one dedicated to the knowledge of infections and sepsis. In the last decade, there has been a virtual explosion of new information in the area, including, among others, the discovering of new antibiotics of broad spectre and important sighting into the mechanisms of cardiovascular dysfunction, several sepsis-induced new cytokines and inflammatory mediators, as well as the role of the L-arginine-nitric oxide pathway in the pathophysiology of sepsis. These advances have provided further expectations in reduction of morbidity and mortality from sepsis, that have not still been confirmed on different phase III clinical trials with immunologic therapies. That have seen undertaken and reported the aim of this issue is reviewing the current concepts and definitions, pathophysiology, prophylaxis, and therapeutic approaches in infection and sepsis.

[The effect of the composition of the enteral nutrition on infection in the critical patient]. / Influencia de la composición de la nutrición enteral en la infección del paciente crítico.

We have conducted a prospective, randomized study to evaluate the influence of the immuno-modulatory nutrition Impact, on septic complications, and on the morbido-mortality of 30 patients who were admitted to our Critical Care Unit. This unit, situated in a tertiary care hospital, is composed of 11 beds, into which are admitted traumatic, medical and surgical patients. The patients admitted to this study had Apache II scores > 10; TISS > 20 and/or CGS > or = 9. The diet of the study was compared with Precitene Hiperproteico. We did not find statistically significant difference in the biochemical-immunological parameters studied, in the incidence of the septic morbido-mortality, nor in the time stayed in the Unit, although in the latter, we observed a tendency towards decrease in those patients who received the supplemented diet.

[Zinc deficiency caused by postgastrectomy fistula with high flow in a patient undergoing prolonged parenteral nutrition]. / Déficit de zinc debido a fístula posgastrectomía de alto débito en paciente sometido a nutrición parenteral prolongada.

A case is presented of a 57-year-old male patient who underwent total gastrectomy due to gastric adenocarcinoma. During the postoperative period the patient required long-term parenteral nutrition due to a high-debit GI fistula (over 700 ml/day) and sepsis. Two months after parenteral nutrition was started, the patients presented irritability, mucocutaneous lesions and progressive bolding. Serum alkaline phosphatase and zinc levels were lower than normal, although a supplemental 0.03 mg/k/day of zinc was administered. Faced with this zinc deficiency picture, 10 mg zinc sulfate was administered parenterally on a daily basis. The deficiency picture improved markedly over a week's period, and serum zinc and alkaline phosphatase levels returned to normal. The importance of zinc balance control in patients under long-term parenteral nutrition and high fluid debit through GI fistulas is highlighted.