[Tako-Tsubo syndrome (transient apical dyskinesia). An entity that can mimic a myocardial infarction]. / Síndrome de Tako-Tsubo (discinesia apical transitoria). Un síndrome que simula un infarto de miocardio.

Tako-Tsubo syndrome or transient apical dyskinesia, is an entity that can mimic an acute coronary event. It is characterized by anginal chest pain with ST-T changes in precordial leads, no coronary obstruction on angiography and a characteristic left ventricular antero-apical dyskinesia that recovers to normal in a few days. This syndrome has been described in Japan, but few cases have been reported in Western countries. We report a case of Tako-Tsubo syndrome after thyroid surgery.

Síndrome de Tako-Tsubo (discinesia apical transitoria). Un síndrome que simula un infarto de miocardio / Tako-Tsubo syndrome (transient apical dyskinesia). An entity that can mimic a myocardial infarction

El syndrome de Tako-Tsubo o disquinesia apical transitoria, es unsíndrome que puede simular un evento coronario agudo. Se caracteriza por dolor precordial anginoso con cambios en el ST y onda T en precordiales, no obstrucción coronaria en la coronariografía y una característica disquinesia antero-apical del ventrículo izquierdo que se normaliza en unos pocos días. Este síndrome ha sido descrito en Japón, pero pocos casos has sido reportados in Occidente. Nosotros presentamos un caso de síndrome de Tako-Tsubo después de una cirugía de tiroides

Tako-Tsubo syndrome or transient apical dyskinesia, is an entity that can mimic an acute coronary event. It is characterized by anginal chestpain with ST-T changes in precordial leads, no coronary obstruction onangiography and a characteristic left ventricular antero-apical dyskinesia that recovers to normal in a few days. This syndrome has been described in Japan, but few cases have been reported in Western countries. We report a case of Tako-Tsubo syndrome after thyroid surgery

Evaluación de un protocolo de perfusión continua de insulina en enfermos críticos / Implementation and evaluation of a protocol for continuous insulin perfusion in critical patients

Objetivo. Analizar la eficacia y la seguridad de un protocolo de infusión continua de insulina para el control de la glucemia entre 100-140 mg/dl, evaluando los resultados mediante un método que considera todas las horas de tratamiento. Diseño. Estudio prospectivo observacional durante un período de dos meses y seguimiento hasta finalizar el tratamiento con insulina en perfusión. Ámbito. Unidad de Cuidados Intensivos polivalente de 23 camas. Pacientes. Cincuenta pacientes consecutivos mayores de 18 años con dos glucemias > 140 mg/dl distanciadas 4-6 horas. Se excluyeron los pacientes con dieta oral. Intervención. La velocidad de perfusión y la frecuencia de monitorización de la glucemia se realizaron de acuerdo con las normas del protocolo por parte del personal de enfermería. Principales variables de interés. Días de perfusión de insulina y número y valor de las glucemias realizadas. Se estudiaron los episodios de hipoglucemia, la glucemia media, el porcentaje de glucemias y de horas que el paciente estaba en cada tramo de glucemia. Resultados. La duración media del tratamiento fue 15,6 días (DE 12). Se recogieron un total de 17.768 horas y 8.111 glucemias. El 55,5% de las glucemias estuvieron entre 100-140 mg/dl, lo que representa el 63,9% de las horas. La glucemia media fue 133 mg/dl. Sólo se produjeron dos episodios de hipoglucemia severa (< 45 mg/dl). Conclusión. El protocolo fue seguro y permitió mantener un control glucémico adecuado. El análisis de todas las horas de tratamiento podría aportar más datos que el simple estudio del porcentaje de glucemias en el rango de la normalidad y la glucemia media

Objective. To analyze the efficacy and safety of a protocol for the continuous infusion of insulin to maintain blood glucose levels between 100 and 140 mg/dl, evaluating the results by a method that takes all of the hours of treatment into consideration. Design. Prospective observational study over a two-month period and follow up until the end of insulin perfusion. Context. Twenty three-bed polyvalent ICU. Patients. Fifty consecutive patients > 18 years of age with 2 episodes of glycemia > 140 mg/dl separated by 4-6 hours. Patients on an oral diet were excluded. Intervention. The perfusion rate and the frequency of glycemia monitoring were set according to the nursing staff’s protocol. Main variables of interest. Days of insulin perfusion and number and value of the blood glucose measurements taken. Episodes of hypoglycemia, mean blood glucose level, the percentage of hyperglycemia episodes, and the number of hours that the patient’s blood glucose was in each range. Results. The mean duration of treatment was 15.6 days (SD 12). A total of 17,768 hours and 8,111 blood glucose measurements were collected. 55.5% of the blood glucose measurements were between 100-140 mg/dl, and this represents 63.9% of the hours. The mean blood glucose level was 133 mg/dl. Only 2 episodes of severe hypoglycemia (< 45 mg/dl) occurred. Conclusion. The protocol was safe and enabled adequate control of blood glucose levels. The analysis of all of the hours of treatment might provide more data than a simple study of the percentages of blood glucose measurements within the normal range and the mean blood glucose level

[Implementation and evaluation of a protocol for continuous insulin perfusion in critical patients]. / Evaluación de un protocolo de perfusión continua de insulina en enfermos críticos.

OBJECTIVE: To analyze the efficacy and safety of a protocol for the continuous infusion of insulin to maintain blood glucose levels between 100 and 140 mg/dl, evaluating the results by a method that takes all of the hours of treatment into consideration. DESIGN: Prospective observational study over a two-month period and follow up until the end of insulin perfusion. CONTEXT: Twenty three-bed polyvalent ICU. PATIENTS: Fifty consecutive patients >18 years of age with 2 episodes of glycemia >140 mg/dl separated by 4-6 hours. Patients on an oral diet were excluded. INTERVENTION: The perfusion rate and the frequency of glycemia monitoring were set according to the nursing staff's protocol. MAIN VARIABLES OF INTEREST: Days of insulin perfusion and number and value of the blood glucose measurements taken. Episodes of hypoglycemia, mean blood glucose level, the percentage of hyperglycemia episodes, and the number of hours that the patient's blood glucose was in each range. RESULTS: The mean duration of treatment was 15.6 days (SD 12). A total of 17,768 hours and 8,111 blood glucose measurements were collected. 55.5% of the blood glucose measurements were between 100-140 mg/dl, and this represents 63.9% of the hours. The mean blood glucose level was 133 mg/dl. Only 2 episodes of severe hypoglycemia (<45 mg/dl) occurred. CONCLUSION: The protocol was safe and enabled adequate control of blood glucose levels. The analysis of all of the hours of treatment might provide more data than a simple study of the percentages of blood glucose measurements within the normal range and the mean blood glucose level.

[Hypokalemia-induced paraplegia secondary to acute diarrhea]. / Paraplejia por hipopotasemia secundaria a diarrea aguda.

Hypokalemia can give a variety of syntomatology but more often courses without it or with inespecific clinical manifestations. In our enviroment the etiology of hypokalemia is wide but one of the most common causes in third world countries are diarrheas. We describe a case of severe hypokalemia due to acute diarrhea which was manifested with severe neurologic symtoms but improves with conventional treatment.

Paraplejia por hipopotasemia secundaria a diarrea aguda / Hipokalemic paraplegia due to acute diarrhea

La hipopotasemia puede dar una clínica variada pero es frecuente que curse de forma asintomática o con síntomas inespecíficos si es de escasa cantidad. En nuestro medio las causas de la hipopotasemia son variadas pero una de las etiologías más frecuentes en paises en vías de desarrollo son los cuadros diarreicos. Presentamos un cuadro de hipopotasemia severa debida a diarrea que se manifestó con intensa clínica neurológica pero que mejoró espectacularmente con tratamiento habitual. (AU)

[Audit of artificial nutrition in an intensive care unit]. / Auditoría de la nutrición artificial en una Unidad de Medicina Intensiva.

OBJECTIVE: To study compliance with an artificial nutrition protocol at an Intensive Care Unit. During a second stage and after introducing the modifications considered appropriate in the protocol, to verify its implementation and compare both series. REFERENCE POPULATION: All patients with artificial nutrition support were included. Artificial nutrition (AN) was deemed to be the dispensation of commercial preparations for enteral nutrition, formulas with amino acids and glucose and the parenteral provision of fat, including propofol in this case, even where it was the only source of energy. The provision of crystalloid solutions was not considered to be AN. The period of observation was two months in both cases. INTERVENTION: The provision of AN to all such patients was systematically recorded on a daily basis. After analysis of the first series, the members at the unit agreed to increase the nitrogen provision. A second series was recorded, with the data being collected for patients with AN during a similar period. RESULTS: The study of the first series revealed the provisions of energy and nitrogen were below theoretical levels (both in the corrected Harris-Benedict test and at the fixed prescription of 25 kcal/kg). In the second series, there was greater agreement between the theoretical values and the amounts actually received. The deviation in energy and nitrogen was significantly less in the second series. And although the total nitrogen load per patient did not reveal any differences, there were discrepancies in the daily provision per patient. On most days, the diet provided covered over 75% of the energy requirements. With parenteral nutrition on its own or in combination with enteral nutrition, the requirements of energy and nitrogen were exceeded. There were no differences between the two series. The type of provision was enteral on 55% of the days and parenteral on 18%. There was no difference in the type of provision between the two series, although there was a difference in the type of diet administered in that the second series saw a significant increase in the provision of hyperproteic diets, both enterally and through patenteral formulations, rising from 9-13 grammes to 18-20 grammes of nitrogen. Using the enteral route on its own, there was a discreet increase in the energy load in the second series, but this did not occur in the other types of provision. Both series revealed over-nutrition in terms of both calories and nitrogen when enteral and parenteral nutrition were used together, although there was no difference between the series. CONCLUSIONS: Early enteral nutrition is possible in critically-ill patients, while artificial nutrition was used most frequently and for longer in our patients. The existence of nutrition protocols allow acceptable levels of nutritional provision. Their controlled use allows the correction of deviations between real and theoretical provisions, customizing the nutrition for each patient. The use of parenteral formulas with high levels of nitrogen requires more accurate adjustment in order to avoid over-nutrition.

Auditoría de la nutrición artificial en una unidad de medicina intensiva / Audit of artificial nutrition at an Intensive Care Unit

Objetivo: Estudiar el cumplimiento de un protocolo de nutrición artificial en una unidad de medicina intensiva. En una segunda fase y tras realizar las modificaciones que se consideraron oportunas de dicho protocolo, comprobar su implementación y contraste entre ambas series. Población de referencia: Se incluyeron a todos los pacientes con soporte de nutrición artificial (NA). Se consideró NA la dispensa de preparados comerciales para nutrición enteral, las formulaciones con aminoácidos y glucosa y el aporte graso parenteral, incluyendo en este caso al propofol, aunque fuese la única fuente calórica. No se consideró NA el aporte de soluciones de cristaloides. El período de observación fue en ambos casos de dos meses. Intervención: Se recogieron de forma sistemática y diaria los aportes de NA, en todos los pacientes nutridos. Tras el análisis de la primera serie se consensuó entre los miembros de la unidad un incremento en el aporte nitrogenado. Realizamos una segunda serie, recogiendo de forma idéntica los datos de los pacientes con NA, durante un período de tiempo similar. Resultados: El estudio de la primera serie mostró unos aportes calóricos y nitrogenados por debajo de los teóricos (tanto en el Harris-Benedict corregido como en la prescripción fija de 25 kcal/kg). En la segunda serie hubo una mejor concordancia entre lo teórico y lo realmente recibido. La desviación calórica y nitrogenada fue menor en la segunda serie de forma significativa. Y aunque la carga nitrogenada total por paciente no mostró diferencias, sí la hubo en el aporte medio diario por paciente. Conclusiones: La nutrición enteral precoz es posible en los pacientes críticos, siendo la nutrición artificial más frecuente y durante más tiempo, empleada en nuestros pacientes. La existencia de protocolos de nutrición permiten unos niveles de aporte nutricional aceptables. Su control en la implementación permiten corregir las desviaciones de aporte real/teórico, ajustando la nutrición a cada paciente. El empleo de fórmulas parenterales con altos niveles de nitrógeno, necesitan un ajuste más preciso, para evitar la sobrenutrición (AU)

Objective: To study compliance with an artificial nutrition protocol at an Intensive Care Unit. During a second stage and after introducing the modifications considered appropriate in the protocol, to verify its implementation and compare both series. Reference population: All patients with artificial nutrition support were included. Artificial nutrition (AN) was deemed to be the dispensation of commercial preparations for enteral nutrition, formulas with amino acids and glucose and the parenteral provision of fat, including propofol in this case, even where it was the only source of energy. The provision of crystalloid solutions was not considered to be AN. The period of observation was two months in both cases. Intervention: The provision of AN to all such patients was systematically recorded on a daily basis. After analysis of the first series, the members at the unit agreed to increase the nitrogen provision. A second series was recorded, with the data being collected for patients with AN during a similar period. Results: The study of the first series revealed the pro-visions of energy and nitrogen were below theoretical levels (both in the corrected Harris-Benedict test and at the fixed prescription of 25 kcal/kg). In the second series, there was greater agreement between the theoretical values and the amounts actually received. The deviation in energy and nitrogen was significantly less in the second series. And although the total nitrogen load per patient did not reveal any differences, there were discrepancies in the daily provision per patient. On most days, the diet provided covered over 75% of the energy requirements. With parenteral nutrition on its own or in combination with enteral nutrition, the requirements of energy and nitrogen were exceeded. The-re were no differences between the two series. The type of provision was enteral on 55% of the days and parenteral on 18%. There was no difference in the type of provision between the two series, although there was a difference in the type of diet administered in that the second series saw a significant increase in the provision of hyperproteic diets, both enterally and through parenteral formulations, rising from 9-13 grammes to 18-20 grammes of nitrogen. Using the enteral route on its own, there was a discreet increase in the energy load in the second series, but this did not occur in the other types of provision. Both series revealed over-nutrition in terms of both calories and nitrogen when enteral and parenteral nutrition were used together, although there was no difference between the series. Conclusions: Early enteral nutrition is possible in critically-ill patients, while artificial nutrition was used most frequently and for longer in our patients. The existence of nutrition protocols allow acceptable levels of nutritional provision. Their controlled use allows the correction of deviations between real and theoretical provisions, customizing the nutrition for each patient. The use of parenteral formulas with high levels of nitrogen requires more accurate adjustment in order to avoid over-nutrition (AU)