Lactato como marcador temprano de hipoxia cerebral en pacientes neurológicos bajo anestesia general: una revisión sistemática / Lactate as an early marker of cerebral hypoxia in neurological patients under general anesthesia: a systematic review

Resumen: Las complicaciones neurológicas perioperatorias secundarias a hipoxia durante procedimientos de sedación y anestesia general son frecuentes en cirugía cardiovascular y en pacientes con comorbilidades. Sin embargo, hasta el momento no existe un consenso para el diagnóstico de estas posibles complicaciones. En pacientes con trauma encefálico severo y/o hemorragia subaracnoidea el lactato cerebral no fue útil para predicción de hipoxia cerebral; pese a ello, la relación de lactato/piruvato podría ser una herramienta para diagnóstico intraoperatorio de hipoxia cerebral aguda. Los estudios sugieren que éste debe asociarse a otros marcadores y/o a monitoreo multimodal. Es necesario realizar estudios que evalúen su valor predictivo para hipoxia cerebral.

Abstract: Perioperative neurological complications secondary to hypoxia during sedation and general anesthesia procedures are frequent in cardiovascular surgery, and in patients with comorbidities. However, so far there is no consensus for the diagnosis of these possible complications. In patients with head trauma severe and/or subarachnoid hemorrhage cerebral lactate was not useful for predicting cerebral hypoxia, however the lactate/pyruvate ratio could be a tool for intraoperative diagnosis of acute cerebral hypoxia. Studies suggest that it must be associated with other markers or multimodal monitoring. Further studies are needed to evaluate lactate predictive value for the diagnosis of cerebral hypoxia.

Clinical characteristics and in-hospital mortality of patients with COVID-19 in Chile: A prospective cohort study.

AIMS OF THIS STUDY: To describe the Latin American population affected by COVID-19, and to determine relevant risk factors for in-hospital mortality. METHODS: We prospectively registered relevant clinical, laboratory, and radiological data of adult patients with COVID-19, admitted within the first 100 days of the pandemic from a single teaching hospital in Santiago, Chile. The primary outcome was in-hospital mortality. Secondary outcomes included the need for respiratory support and pharmacological treatment, among others. We combined the chronic disease burden and the severity of illness at admission with predefined clinically relevant risk factors. Cox regression models were used to identify risk factors for in-hospital mortality. RESULTS: We enrolled 395 adult patients, their median age was 61 years; 62.8% of patients were male and 40.1% had a Modified Charlson Comorbidity Index (MCCI) ≥5. Their median Sequential Organ Failure Assessment (SOFA) score was 3; 34.9% used a high-flow nasal cannula and 17.5% required invasive mechanical ventilation. The in-hospital mortality rate was 14.7%. In the multivariate analysis, were significant risk factors for in-hospital mortality: MCCI ≥5 (HR 4.39, P < .001), PaO2 /FiO2 ratio ≤200 (HR 1.92, P = .037), and advanced chronic respiratory disease (HR 3.24, P = .001); pre-specified combinations of these risk factors in four categories was associated with the outcome in a graded manner. CONCLUSIONS AND CLINICAL IMPLICATIONS: The relationship between multiple prognostic factors has been scarcely reported in Latin American patients with COVID-19. By combining different clinically relevant risk factors, we can identify COVID-19 patients with high-, medium- and low-risk of in-hospital mortality.

MMSE items that predict incident delirium and hypoactive subtype in older medical inpatients.

Because hypoactive delirium is especially under-recognized, we analyzed which Mini-Mental State Examination (MMSE) items predicted incident delirium and its hypoactive motor presentation. Over a 1-year period, older medical inpatients (n=291) were consecutively screened on admission with the Confusion Assessment Method-Spanish (CAM-S) to exclude prevalent delirium. Nondelirious patients were evaluated the same day with the MMSE, followed by daily ratings with the CAM-S. Those who became CAM-S positive were rated using the Delirium Rating Scale-Revised-98 to assess severity and motor subtype. Disorientation to time (OR 4.4, 95% CI 1.7-11.1) and place (OR 3.8, 95% CI 1.7-8.2) at admission were risk factors for delirium at follow-up and together correctly classified 88.3% of subjects as to delirium status. Disorientation to time and place, and visuoconstructional impairment were each associated with either hypoactive or mixed subtype (p<0.05 χ(2) test). Simple bedside evaluation of cognitive function in nondelirious patients revealed deficits that detected patients at risk for developing incident delirium at follow-up (especially hypoactive or mixed). We recommend patients with orientation deficits be monitored closely for emergence of delirium. A separate evaluation for possible dementia or other causes of cognitive impairment at admission should be considered too.

[Thoracic actinomycosis in the differential diagnosis of neoplasm: a propos of a case]. / Actinomicosis torácica como diagnóstico diferencial de neoplasia: a propósito de un caso.

Actinomycosis is an infrequent infection caused by bacteria from Actinomyces genus that manifests as a chronic, suppurative and progressive disease. It's more common in men. Thoracic actinomycosis occurs in 15% of the cases, and infection of the chest wall is less frequent. The clinical presentation mimics tuberculosis or neoplastic processes. In this article we present the case of a 63 year-old man with no comorbidity, with pulmonary actinomycosis involving the chest wall mimicking a neoplastic process, basing the diagnosis on histopathologic findings.

Actinomicosis torácica como diagnóstico diferencial de neoplasia: a propósito de un caso / Thoracic actinomycosis in the differential diagnosis of neoplasm: a propos of a case

Actinomycosis is an infrequent infection caused by bacteria from Actinomyces genus that manifests as a chronic, suppurative and progressive disease. It's more common in men. Thoracic actinomycosis occurs in 15% of the cases, and infection of the chest wall is less frequent. The clinical presentation mimics tuberculosis or neoplastic processes. In this article we present the case of a 63 year-old man with no comorbidity, with pulmonary actinomycosis involving the chest wall mimicking a neoplastic process, basing the diagnosis on histopathologic findings.

La actinomicosis es una infección poco común causada por bacterias del género Actinomyces que se manifiesta como una enfermedad crónica, supurativa y progresiva. Es más frecuente en hombres. La actinomicosis torácica se presenta en 15% de los casos, siendo el compromiso de pared torácica aún menos frecuente. La presentación clínica simula procesos neoplásicos o tuberculosis. Se describe el caso de un hombre de 63 años, sin co-morbilidad, con una actinomicosis pulmonar con compromiso de pared torácica que simuló ser un proceso neoplásico. El diagnóstico fue confirmado por los hallazgos histopatológicos.

Relationship between cognitive status at admission and incident delirium in older medical inpatients.

To evaluate the relationship between cognitive status and incident delirium, 291 geriatric patients on internal medicine wards were evaluated on admission with the Mini-Mental State Examination (MMSE) and Confusion Assessment Method-Spanish. Those with incident delirium were assessed using the Delirium Rating Scale-Revised-98 (DRS-R98). Delirium incidence was 11.7%, and 82 patients (28.2%) had cognitive deficits on MMSE. As cognitive impairment worsened, the risk for delirium increased linearly, and for each unit of MMSE worsening the DRS-R98 severity score worsened 0.4 points (F=5.39, df=1, p=0.027). Optimal MMSE cutoff score from receiver-operating characteristic curve analysis was 24.5. Even mild cognitive deficits increase delirium risk and severity.

[Charles Bonnet syndrome: report of one case managed with haloperidol]. / Síndrome de Charles Bonnet: Manejo con haloperidol en paciente nonagenaria. Caso clínico.

Charles Bonnet syndrome is an underrecognized condition characterized by complex visual hallucinations, ocular problems causing visual deterioration and preserved cognitive status. Its prevalence is 5/1000 in ambulatory ophthalmologic patients. Generally occurs in elderly people in whom it may be confused with delirium or dementia. The first management step is to improve vision, if possible. Hallucinations may be managed pharmacologically. We report a 94 year-old woman with the characteristic clinical picture of the syndrome that improved with haloperidol.

Síndrome de Charles Bonnet: Manejo con haloperidol en paciente nonagenaria. Caso clínico / Charle Bonnet syndrome: Report of one case managed with haloperidol

Charles Bonnet syndrome is an underrecognized condition characterized by complex visual hallucinations, ocular problems causing visual deterioration and preserved cognitive status. Its prevalence is 5/1000 in ambulatory ophthalmologic patients. Generally occurs in elderly people in whom it may be confused with delirium or dementia. The first management step is to improve vision, if possible. Hallucinations may be managed pharmacologically. We report a 94 year-old woman with the characteristic clinical picture of the syndrome that improved with haloperidol.