Vitamina C, tiamina e hidrocortisona: ¿aliados en shock séptico? / Vitamin C, thiamine and hydrocortisone: allies against septic shock?

Objetivo: Determinar la efectividad del uso de un protocolo de vitamina C, tiamina e hidrocortisona en shock séptico a las dosis empleadas en el estudio Marik. Método: Estudio observacional retrospectivo antes-después que compara dos grupos de pacientes con shock séptico: grupo tratamiento (GT), tratado con el protocolo, desde enero 2019 a mayo 2020, frente a un grupo control (GC) en un periodo previo. Los objetivos principales fueron la supervivencia a los 14 y a los 28 días. Resultados: Se incluyeron 91 pacientes, 44 en GC y 47 en GT. No se encontraron diferencias estadísticamente significativas en la supervivencia a los 14 ni a los 28 días ni en la duración de estancia hospitalaria ni en la Unidad de Reanimación (REA) (p>0,05). La variación de los valores de creatinina entre los días 1 y 4 presentó una mediana de -0,04 (RIC -0,24;0,8) en el GC frente a -0,3 del GT (RIC -0,079;-0,03), p<0,05. Los valores de procalcitonina descendieron en el 27,3% de los pacientes del GC frente al 91,5% del GT (p<0,05). La necesidad de soporte vasoactivo con noradrenalina fue del 93% GC vs 76,6% GT en el día 2; 75% GC vs 55,3% GT en el día 3; 50% GC vs 27,7% GT en el día 4 (p<0,05). Conclusiones: Los datos de nuestro estudio muestran un beneficio limitado del uso del protocolo en pacientes con shock séptico, pero son necesarios estudios de mayor reclutamiento con un diseño prospectivo randomizado para asegurar el beneficio real y/o dosis óptimas. (AU)

Objective: To determine the effectiveness of using a protocol of vitamin C, thiamine and hydrocortisone for the treatment of septic shock at the doses used in the Marik study. Methods: Retrospective observational before-after study comparing two groups of patients with septic shock: treatment group (GT), treated with the protocol, between January 2019 and May 2020, versus a control group (GC) in a previous period. The primary outcomes were 14-Day and 28-Day Survival. Results: 91 patients were included, 44 in GC and 47 in GT. No statistically significant differences were found in 14-day and 28-day survival, in length of hospital or Resuscitation Unit (REA) stay (p>0.05). The median creatinine variation between days 1 and 4 was -0.04 (IQR -0.24;0.8) in the GC vs -0.3 in the GT (IQR -0.079; -0.03) (p<0.05). Procalcitonin values decreased in 27.3% of GC versus 91.5% of GT (p<0.05). The need for vasoactive drugs (noradrenaline) was 93% in GC vs 76.6% GT on day 2; 75% GC vs 55.3% GT on day 3; 50% GC vs 27.7% GT on day 4 (p<0.05). Conclusions: Our results show a limited benefit of the use of the protocol in patients with septic shock, but larger recruitment studies with a prospective randomized design are needed to ensure real benefit and/or optimal doses. (AU)

Intrathecal magnesium as analgesic adjuvant for spinal anesthesia: a meta-analysis of randomized trials.

BACKGROUND: The efficacy and safety of intrathecal magnesium as analgesic adjuvant has been tested by several clinical trials in recent years. We performed a meta-analysis of the available literature. METHODS: Randomized clinical trials comparing a 50 to 100 mg dose of intrathecal magnesium sulfate versus placebo in addition to an intrathecal local anesthetic and/or opiate for a below-umbilicus procedure were included. Medline, LILACS, Cochrane Library and Google Scholar databases were searched. A random analysis was performed and heterogeneity was tested for. The size of the effect for quantitative outcomes was calculated as standard mean difference (SMD, neutral=0); and as odds ratio (OR, neutral=1) for dichotomous outcomes. RESULTS: Twelve studies totaling 817 patients were included. The "time to first analgesia request" was at least 35 minutes longer when intrathecal magnesium was included in the intervention (SDM 0.94, 95%CI 0.51 to 1.37, P<0.001). The "onset time to sensory block" (SDM 0.64, 95%CI 0.15 to 1.12, P=0.01) and the "time to maximal motor block" (SDM 0.97, 95%CI 0.28 to 1.67, P=0.006) were 2.4 minutes slower with intrathecal magnesium. There was no difference in "time to full motor recovery, incidence of pruritus, postoperative nausea and vomiting, bradicardia, low blood pressure and urinary retention". No cases of respiratory depression or neurotoxicity were recorded in these studies. CONCLUSION: The inclusion of 50 to 100 mg of intrathecal magnesium in a spinal anesthetic prolongs opiate analgesia duration; no safety concerns have been identified by the included clinical studies but additional evidence is advised.

Shock séptico. Actualización en tratamiento con suero salino hipertónico y hormona antidiurética-vasopresina / Septic shock. Update of treatment using hypertonic saline and antidiuretic hormone-vasopressin

La seguridad en el uso del suero salino hipertónico ha sido comprobada por estudios en el campo de la reanimación con pequeños volúmenes para el shock hipovolémico y en el tratamiento de la hipertensión intracraneal. En el ámbito del shock séptico, ha sido poco experimentado en seres humanos. Existen efectos inmunomodulatorios beneficiosos detectados en estudios preclínicos. Las interacciones con el eje hipofisario-adrenal y con la secreción de la hormona antidiurética son diversas y sugerentes, pero insuficientemente entendidas. Por otra parte, la vasopresina ejerce acciones cardiovasculares, osmorreguladoras, sobre la coagulación y también sobre el eje hipotálamo-hipofisario-adrenal. En el shock séptico hay un déficit relativo de vasopresina. Su uso en estos pacientes no parece presentar ventajas en cuanto a la mortalidad, pero puede ser beneficioso en pacientes en riesgo de insuficiencia renal aguda o en aquellos que reciben corticoides. La terlipresina es un análogo de la vasopresina que también se ha estudiado. La sinergia entre la vasopresina y el suero salino hipertónico es una hipótesis que se fundamenta, sobre todo, en estudios preclínicos. El uso del suero salino hipertónico en el shock séptico sigue siendo experimental, aunque prometedor, y debe quedar restringido al campo de los ensayos clínicos controlados(AU)

Safety in the use of small volumes of hypertonic saline solution for hypovolaemic shock and in the treatment of intracranial hypertension has been demonstrated in studies in the field of resuscitation. There is little experience of this for septic shock in humans. Beneficial immunomodulatory effects have been detected in pre-clinical studies. Interactions with the pituitary-adrenal axis and with the secretion of anti-diuretic hormone are varied and suggestive, but are not sufficiently understood. On the other hand, vasopressin has cardiovascular, osmoregulatory, and coagulation effects, and also acts on the hypothalamic-pituitary-adrenal axis. There is a relative deficit of vasopressin in septic shock. Its use in these patients does seem to have any advantages as regards mortality, but may be beneficial in patients at risk from acute renal failure, or those who receive corticosteroids. Terlipressin is a vasopressin analogue that has also been studied. The synergy between vasopressin and hypertonic saline is a hypothesis that is mainly supported in pre-clinical studies. The use of hypertonic saline solution in septic shock, although promising, is still experimental, and must be restricted to the field of controlled clinical trials(AU)

[Septic shock. Update of treatment using hypertonic saline and antidiuretic hormone-vasopressin]. / Shock séptico. Actualización en tratamiento con suero salino hipertónico y hormona antidiurética-vasopresina.

Safety in the use of small volumes of hypertonic saline solution for hypovolaemic shock and in the treatment of intracranial hypertension has been demonstrated in studies in the field of resuscitation. There is little experience of this for septic shock in humans. Beneficial immunomodulatory effects have been detected in pre-clinical studies. Interactions with the pituitary-adrenal axis and with the secretion of anti-diuretic hormone are varied and suggestive, but are not sufficiently understood. On the other hand, vasopressin has cardiovascular, osmoregulatory, and coagulation effects, and also acts on the hypothalamic-pituitary-adrenal axis. There is a relative deficit of vasopressin in septic shock. Its use in these patients does not seem to have any advantages as regards mortality, but may be beneficial in patients at risk from acute renal failure, or those who receive corticosteroids. Terlipressin is a vasopressin analogue that has also been studied. The synergy between vasopressin and hypertonic saline is a hypothesis that is mainly supported in pre-clinical studies. The use of hypertonic saline solution in septic shock, although promising, is still experimental, and must be restricted to the field of controlled clinical trials.

Síndrome coronario agudo sintomático en el seguimiento de una cohorte en el postoperatorio de cirugía no cardiaca / Symptomatic acute coronary syndrome in a cohort of patients followed after noncardiac surgery

Objetivo: Determinar la incidencia del síndrome coronario agudo (SCA) sintomático con y sin elevación del ST, los factores con los que se relacionó, la estancia media y la mortalidad atribuible en el periodo postoperatorio en pacientes de cirugía no cardiaca. Material y métodos: Se registraron prospectivamente los datos de una cohorte de pacientes intervenidos de cirugía no cardíaca que pasaron por la unidad de reanimación postoperatoria del Hospital General de Ciudad Real en el periodo comprendido entre abril de 2006 y diciembre de 2009. Se evaluó la incidencia de SCA sintomático. Resultados: Treinta y dos de 1.919 pacientes presentaron SCA (incidencia 1,7%). Los factores asociados fueron: sexo varón (p = 0,046), edad (p = 0,001), hipertensión arterial (68,8%; p = 0,012) y cardiopatía isquémica previa (34,4% p = 0,001). Los pacientes que sufrieron intervenciones quirúrgicas que presentaron SCA postoperatorio de forma significativa (p < 0,004) fueron cirugía general (37,5%), ortopedia-traumatología (28,1%) y cirugía vascular (15,6%). Fueron transfundidos el 20% de los pacientes en general, y el 50% de los que tuvieron SCA (p = 0,001). El tratamiento fue médico en el 87,5% de los pacientes. La estancia media de los pacientes en la unidad fue de 2,96 ± 6,3 días frente a 3,88 ± 5 días en los pacientes con SCA (p = 0,39) y la mortalidad del 5% frente al 6% respectivamente (p = 0,45). El análisis multivariante mostró como variables independientes para presentar SCA en el periodo postoperatorio: antecedentes de cardiopatía isquémica (OR = 4,59; IC 95% 1,98-10,62), y sangrado quirúrgico (OR =3,18; IC 95%, 1,51-6,71). La cirugía ginecológica (OR = 0,063; IC 95%, 0,004-1,09) mostró la menor probabilidad de presentar dicha alteración en el postoperatorio. Conclusión: La incidencia de SCA en nuestra cohorte en el postoperatorio de cirugía no cardiaca es del 1,7%. Son factores de riesgo la edad, el sexo masculino, los antecedentes de hipertensión arterial y cardiopatía isquémica, el tipo de cirugía y la hemorragia operatoria que precisó transfusión de concentrados de hematíes. Dada la gravedad de esta complicación es importante estratificar el riesgo de estos pacientes preoperatoriamente(AU)

Objetives: To determine the incidence of acute coronary syndrome (ACS) with and without ST-segment elevation, factors related to the development of ACS, mean hospital stay, and attributable mortality. Material and methods: In a noncardiac surgery cohort attended in the postoperative critical care unit of Hospital General de la Ciudad Real, Spain, data were recorded prospectively between April 2006 and December 2009. The incidence of symptomatic ACS was calculated. Results: Thirty-two of 1919 patients developed ACS (incidence, 1.7%). Patient factors related to developing the syndrome were male sex (P=.046), age (P=.001), arterial hypertension (68.8%, P=.012), and a history of ischemic heart disease (34.4%, P=.001). Types of surgery that were significantly related to developing ACS were general surgery (37.5%), orthopedic or trauma surgery (28.1%), and vascular surgery (15.6%) (P<.004). Twenty percent of the cohort received transfusions; 50% of those who developed ACS were transfused (P=.001). The condition was treated medically in 87.5% of the cases. The mean (SD) duration of hospital stay was 2.96 (6.3) days for the cohort and 3.88 (5) days for patients who developed ACS (P=.39); mortality rates were 5% and 6%, respectively (P=.45). Multivariate analysis confirmed that the following independent variables were associated with developing postoperative ACS: a history of ischemic heart disease (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.98-10.62) and intraoperative bleeding (OR, 3.18; 95% CI, 1.51-6.71). Gynecologic surgery patients were the least likely to develop postoperative ACS (OR, 0.063; 95% CI, 0.004-1.09). Conclusions: The incidence of postoperative ACS in this noncardiac surgery cohort was 1.7%. Age, male sex, a history of arterial hypertension or ischemic heart disease, type of surgery, and intraoperative bleeding requiring transfusion of packed red blood cells are factors that are associated with developing this complication. Given the seriousness of ACS it is important to classify patients by risk before surgery(AU)

[Symptomatic acute coronary syndrome in a cohort of patients followed after noncardiac surgery]. / Síndrome coronario agudo sintomático en el seguimiento de una cohorte en el postoperatorio de cirugía no cardiaca.

OBJECTIVES: To determine the incidence of acute coronary syndrome (ACS) with and without ST-segment elevation, factors related to the development of ACS, mean hospital stay, and attributable mortality. MATERIAL AND METHODS: In a noncardiac surgery cohort attended in the postoperative critical care unit of Hospital General de la Ciudad Real, Spain, data were recorded prospectively between April 2006 and December 2009. The incidence of symptomatic ACS was calculated. RESULTS: Thirty-two of 1919 patients developed ACS (incidence, 1.7%). Patient factors related to developing the syndrome were male sex (P=.046), age (P=.001), arterial hypertension (68.8%, P=.012), and a history of ischemic heart disease (34.4%, P=.001). Types of surgery that were significantly related to developing ACS were general surgery (37.5%), orthopedic or trauma surgery (28.1%), and vascular surgery (15.6%) (P<.004). Twenty percent of the cohort received transfusions; 50% of those who developed ACS were transfused (P=.001). The condition was treated medically in 87.5% of the cases. The mean (SD) duration of hospital stay was 2.96 (6.3) days for the cohort and 3.88 (5) days for patients who developed ACS (P=.39); mortality rates were 5% and 6%, respectively (P=.45). Multivariate analysis confirmed that the following independent variables were associated with developing postoperative ACS: a history of ischemic heart disease (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.98-10.62) and intraoperative bleeding (OR, 3.18; 95% CI, 1.51-6.71). Gynecologic surgery patients were the least likely to develop postoperative ACS (OR, 0.063; 95% CI, 0.004-1.09). CONCLUSIONS: The incidence of postoperative ACS in this noncardiac surgery cohort was 1.7%. Age, male sex, a history of arterial hypertension or ischemic heart disease, type of surgery, and intraoperative bleeding requiring transfusion of packed red blood cells are factors that are associated with developing this complication. Given the seriousness of ACS it is important to classify patients by risk before surgery.

[Sagittal sinus thrombosis as a rare cause of postpartum headache: a case report]. / Trombosis del seno sagital cerebral: causa infrecuente de cefalea del postparto: a propósito de un caso.

Postpartum cerebral vein thrombosis is a very rare entity (3-4 cases per million). Clinical manifestations vary, though persistent headache is almost always reported, meaning that differential diagnosis should be performed to rule out other causes of postpartum headache. Recognized risk factors for this disease are the prothrombotic state of pregnancy (third trimester), excess weight, and thrombophilia Accidental dural puncture, protein C and S deficiencies, factor V Leiden mutation, antiphospholipid syndrome, and the use of oral contraceptives have also been implicated. The diagnostic test of choice is magnetic resonance imaging, as it is convenient and harmless, though transcranial Doppler ultrasound can also be used. Pulmonary angiography is the gold-standard test. The treatment of choice is anticoagulant therapy with heparin (a treatment that is controversial, however, due to the high risk of rebleeding), followed by long-term treatment with antivitamin K drugs. We report a case of thrombosis of the upper longitudinal sinus associated with persistent postpartum headache and a history of a failed attempt at epidural puncture for analgesia during labor. The case posed interesting diagnostic questions.

Trombosis del seno sagital cerebral: causa infrecuentede cefalea del postparto: a propósito de un caso / Sagittal sinus thrombosis as a rare cause of postpartum headache: a case report

Las trombosis venosas cerebrales del postparto sonuna entidad muy poco frecuente (3-4 casos por millón).Sus manifestaciones clínicas son variadas, siendo la cefaleapersistente casi una constante, lo que implica hacerun diagnóstico diferencial con otras causas de cefaleadurante el puerperio. Los factores predisponentes reconocidosde ésta patología son el estado protrombótico delembarazo (tercer trimestre), el sobrepeso y la existenciade trombofilias. Además se han implicado en su producciónla punción dural accidental, la existencia de deficienciasde proteína C y S, Factor V Leiden, el síndromeantifosfolípido e ingesta de anticonceptivos orales. Laprueba diagnóstica de elección es por su comodidad einocuidad la resonancia magnética, aunque puede utilizarsetambién la ecografía Doppler transcraneal. Laarteriografía es la prueba de referencia. El tratamientode elección es la anticoagulación con heparina (controvertidopor el riesgo elevado de nuevo sangrado), seguidade fármacos antivitamina K durante largos periodos.Describimos un caso de trombosis de seno longitudinalsuperior en el contexto de una cefalea persistente duranteel puerperio con el antecedente de intento fallido depunción epidural para analgesia de trabajo de parto quesupuso un interesante dilema diagnóstico (AU)

Postpartum cerebral vein thrombosis is a very rareentity (3-4 cases per million). Clinical manifestationsvary, though persistent headache is almost alwaysreported, meaning that differential diagnosis should beperformed to rule out other causes of postpartumheadache. Recognized risk factors for this disease are theprothrombotic state of pregnancy (third trimester),excess weight, and thrombophilia Accidental duralpuncture, protein C and S deficiencies, factor V Leidenmutation, antiphospholipid syndrome, and the use of oralcontraceptives have also been implicated. The diagnostictest of choice is magnetic resonance imaging, as it isconvenient and harmless, though transcranial Dopplerultrasound can also be used. Pulmonary angiography isthe gold-standard test. The treatment of choice isanticoagulant therapy with heparin (a treatment that iscontroversial, however, due to the high risk ofrebleeding), followed by long-term treatment withantivitamin K drugs. We report a case of thrombosis ofthe upper longitudinal sinus associated with persistentpostpartum headache and a history of a failed attempt atepidural puncture for analgesia during labor. The caseposed interesting diagnostic questions (AU)