A. González-Castro

Tracheal rupture after endotracheal intubation: a literature systematic review

We aim to perform a systematic review and meta-analysis of the cases of postintubation tracheal rupture (PiTR) published in the literature, with the aim of determining the risk factors that contribute to tracheal rupture during endotracheal intubation. A further objective has been to determine the ideal treatment for this condition (surgical repair or conservative management). A MEDLINE review of cases of tracheal rupture after intubation published in the English language and a review of the references in the articles found. The articles included were those that reported at least the demographic data (age and sex), the treatment performed, and the outcome. Those papers that did not detail the above variables were excluded. The search found 50 studies that satisfied the inclusion criteria. These studies included 182 cases of postintubation tracheal rupture. The overall mortality was 22% (40 patients). A statistical analysis was performed determining the relative risk (RR), 95% confidence intervals (95% CI) and/or statistical significance. The analysis was performed on the overall group and after dividing into 2 subgroups: patients in whom the lesion was detected intraoperatively, and other patients. Patient age (p=0.015) and emergency intubation (RR=3.11; 95% CI, 1.81-5.33; p=0.001) were variables associated with an increased mortality. In those patients in whom the PiTR was detected outside the operating theatre (delayed diagnosis), emergency intubation (RR=3.05; 95% CI, 1.69-5.51; p<0.0001), the absence of subcutaneous emphysema (RR=2.17; 95% CI, 1.25-4; p=0.001), and surgical treatment (RR=2.09; 95% CI, 1.08-4.07; p=0.02) were associated with an increased mortality. In addition, age (p=0.1) and male gender (RR=1.89; 95% CI, 0.98-3.63; p=0.13) showed a clear trend towards an increased mortality. PiTR is an uncommon condition but carries a high morbidity and mortality. Emergency intubation is the principal risk factor, increasing the risk of death threefold compared to elective intubation. Conservative treatment is associated with a better outcome. However, the group of patients who would benefit from surgical treatment has not been fully defined. Further studies are required to evaluate the best treatment options.

Early complications of high-dose methylprednisolone in acute spinal cord injury patients

BACKGROUND To evaluate the early complications and effect on neurological outcome of methylprednisolone (MP) treatment in spinal cord injury (SCI) patients during the acute phase. METHODS We retrospectively reviewed the whole cohort of patients admitted to our ICU between January 1994 and December 2005 due to acute SCI. Patients were grouped according to the medical treatment received (MP group versus no-MP group). Patient data as age, gender, Glasgow coma score (GCS), APACHE II, injury severity score (ISS) and ICU stay were recorded. Outcome at ICU discharge and neurological function based on Frankel grade was recorded at ICU admission and at ICU discharge. Early complications were also noted. RESULTS There were no differences between both groups in ICU mortality (OR=0.48; 95% CI: 0.08-3.64) nor neurological function at ICU discharge. (OR=1.09; 95% CI: 0.35-3.66). MP group presented an increase in respiratory tract infections (OR=8.19; 95% CI: 1.10-358.6) and in total infections (OR=4.90; 95% CI: 1.46-18.83) compared to no-MP group during the ICU stay. There was a significant increase in the incidence of hyperglycaemia in the MP group (OR=17.0; 95% CI: 4.52-66.3). CONCLUSIONS The use of MP in patients with acute SCI is not associated with an improvement in outcome or neurological function at ICU discharge. Moreover, the use of MP is associated with an increased risk of infectious and metabolic complications during ICU stay.

Valor pronóstico del aclaramiento de procalcitonina, PCR y leucocitos en el shock séptico

OBJECTIVES This study evaluates the potential prognostic value of serial measurements of different biomarkers (procalcitonin [PCT], C-reactive protein and leukocytes [CRP]) in septic shock patients. DESIGN Prospective observational study. SETTING Intensive care unit of a third-level University Hospital. PATIENTS The study comprised a total of 88 septic shock patients defined using the 2001 Consensus Conference SCCM/ESICM/ACCP/ATS/SIS criteria. The PCT, CRP and leukocytes were recorded on admission to the ICU and again 72 hours after admission. INTERVENTIONS None. RESULTS Those patients with increasing procalcitonin levels showed higher hospital mortality than those with a decreasing levels (58.8% vs. 15.4%, P<0.01). No such effect was observed in relation to C-reactive protein or leukocytes. The best area under the curve for prognosis was for procalcitonin clearance (0.79). A procalcitonin clearance of 70% or higher offered a sensitivity and specificity of 94.7% and 53%, respectively. CONCLUSIONS Serial procalcitonin measurements are more predictive of the prognosis of septic shock patients than single measurements of this parameter. The prognostic reliability of the latter is also better than in the case of C-reactive protein and leukocytes. The application of serial procalcitonin measurements may allow the identification of those septic patients at increased mortality risk, and help improve their treatment.

Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos

OBJECTIVE Compare the influence of two preservation liquids, Euro-Collins (EC) and Perfadex (P) in the pulmonary graft function in the initial phase of lung transplant in humans. DESIGN Retrospective study. SCOPE Lung transplant unit of the ICU of a university hospital. PATIENTS A total of 79 patients were subjected to a transplant of both lungs. The pulmonary grafts were preserved with EC in 23 cases and with P in 56 cases. VARIABLES OF INTEREST Pulmonary function was assessed on admission in the intensive care unit (ICU) with the PaO2/FiO2 ratio. Mortality, graft dysfunction stay in ICU and time of mechanical ventilation were also assessed at 30 days. RESULTS The PaO2/FiO2 ratio was significantly greater in the P group than in the EC both on admission (p<0.006) and at 12 hours (p=0.032) in the ICU. Graft dysfunction incidence was less in group P than in EC (p<0.045). There were no differences in regards to mortality at 30 days, stay in ICU and time of mechanical ventilation between both groups. CONCLUSION Preservation of the pulmonary graft with P as preservation liquid compared with EC is associated with better graft function in the initial phases of transplant of both lungs and with a decrease in the incidence of graft dysfunction.

Pulmonary venous obstruction after lung transplantation. Diagnostic advantages of transesophageal echocardiography

Abstract:  Pulmonary venous vascular complications after lung transplantation are rare and a major cause of morbidity and mortality unless diagnosed and treated early. The epidemiological, diagnostic, and management characteristics of 33 patients (two of them in our hospital) with post‐transplant pulmonary vein obstruction published in the literature were reviewed. We consider of utmost importance to differentiate stenosis from thrombosis as the cause of the obstruction. The angiography, considered the gold standard for diagnosis, was replaced by transesophageal echocardiography (TEE) in 79% of the cases, but no echocardiographic diagnostic criteria were defined. A diameter of the pulmonary veins, with 2D/color TEE, <0.5 cm, peak systolic flow velocity (PSFV) >1 m/s, pulmonary vein‐left atrial pressure gradient (PVLAG) ≥10–12 mmHg, non‐permeable flow through the stenosis and the presence of thrombus at that level, must lead us to suspect this complication. Higher mortality rates were found in unilateral procedures and in women. We consider that TEE must be carried out as part of the intraoperative routine or within the first 24 h of the post‐operative period.

Mortality Analysis of Patients Undergoing Lung Transplantation for Emphysema

Abstract Background The outcomes of lung transplantation 11 years after starting the transplantation program in our hospital are presented. Risk factors associated with short-, medium-, and long-term mortality in transplant recipients were analyzed. Patients and Methods All patients diagnosed with emphysema who underwent lung transplantation between March 1997 and June 2008 were included. The association between different study variables and early death and death at 1 year and 5 years was studied. The Kaplan-Meier method was used to analyze survival. A logistic regression model was used to study the association between early death and variables with a trend towards significance (P Results A total of 92 patients were included. Survival was 89.3%, 70%, and 54% at 1 month, 1 year, and 5 years after transplantation, respectively. Dehiscence of the surgical suture (P Conclusions Complications were responsible for short-term mortality, while age of the recipient was the most important factor in determining long-term survival. Mortality was higher in single-lung transplant recipients compared to double-lung transplant recipients.

Influence of donor-recipient gender mismatch in early outcome after lung transplantation.

OBJECTIVE Donor and recipient genders are not considered in lung transplantation (LT) programs. However, recent data have suggested a possible biologic effect of gender combination on the outcome of LT. We ought to evaluate the effect of gender combinations on early survival in a single-institution experience in transplant recipients. METHODS We analyzed the potential effect of donor-recipient gender combinations (male [M] or female [F]) on early survival of all patients whose LTs were performed between January 1999 and December 2006. Patients were distributed into 4 groups: M donor to M recipient (M-M group); M donor to F recipient (M-F group); F donor to F recipient (F-F group); and F donor to M recipient (F-M group). The comparison between groups was performed using two-tailed Fisher exact test and analysis of variance (ANOVA). RESULTS During the study period, 152 LTs were performed in 149 patients, including 99 male donors and 53 female donors. The mean age of the recipients was 54 +/- 10 years (range, 14-70). The 30-day survival rate was 86% (95% confidence interval [CI], 77%- 92%) for the M-M group, 67% (95% CI, 41%-87%) for the F-M group, 89% (95% CI, 52%-100%) for the M-F group, and 83% (95% CI, 66%-93%) for the F-F group. No differences were observed between group survivals according to the Fisher test (P = .27). CONCLUSIONS We found no association between donor-recipient gender mismatch and improved survival in lung transplant recipients. Further investigation is needed to finally understand the possible role of gender combinations in LT.

Trasplante de pulmón en casos de enfisema: análisis de la mortalidad

BACKGROUND The outcomes of lung transplantation 11 years after starting the transplantation program in our hospital are presented. Risk factors associated with short-, medium-, and long-term mortality in transplant recipients were analyzed. PATIENTS AND METHODS All patients diagnosed with emphysema who underwent lung transplantation between March 1997 and June 2008 were included. The association between different study variables and early death and death at 1 year and 5 years was studied. The Kaplan-Meier method was used to analyze survival. A logistic regression model was used to study the association between early death and variables with a trend towards significance (P<.2) in the univariate analysis. The risk factors for mortality at 1 year and 5 years were analyzed by a Cox regression model. RESULTS A total of 92 patients were included. Survival was 89.3%, 70%, and 54% at 1 month, 1 year, and 5 years after transplantation, respectively. Dehiscence of the surgical suture (P<.001), duration of mechanical ventilation in the intensive care unit (P=.04), duration of the surgical procedure (P<.001), and single-lung transplantation (P=.007) were the variables associated with mortality. Extracorporeal circulation and the need for hemodiafiltration in the intensive care unit increased the short-term risk of death (P<.05). The age of the recipient was the variable associated with long-term mortality (P=.02). The duration of the surgical intervention was associated with an increase in short-, medium-, and long-term mortality. CONCLUSIONS Complications were responsible for short-term mortality, while age of the recipient was the most important factor in determining long-term survival. Mortality was higher in single-lung transplant recipients compared to double-lung transplant recipients.

Trasplante pulmonar con donantes de edad marginal (≥ 55 años)

OBJECTIVE We analyzed short, medium and long-term mortality in transplant recipients who received lungs from donors aged 55 years or more. PATIENTS AND METHODS All patients who underwent lung transplantation from donors aged 55 years or more were included. The association between the different study variables and early death and death at 1 year and 5 years was studied. A logistic regression model was used to study the association between early death and variables with a trend towards significance (P<.2) in the bivariate analysis. The risk factors for mortality at 1 year and 5 years were analyzed with a Cox regression model. The Kaplan-Meier method was used to analyze survival. RESULTS A total of 33 patients were included. The probability of survival was 90.9%, 78.5% and 44.8% at 1 month, 1 year, and 5 years after lung transplantation, respectively. The elevated age of the recipient (P=.16) and single-lung transplantation (P=.09) were the variables associated to or with a trend towards significant associations with mortality. CONCLUSIONS The final decision to accept a lung graft should be based on individual evaluation of each donor and recipient. However, given the lack of lung donors, donors aged 55 years or more should be considered for lung transplantation.

Valor de la fracción de espacio muerto (Vd/Vt) como predictor de éxito en la extubación

PURPOSE To determine the value of Vd/Vt as a predictor of extubation failure in patients with mechanical ventilation admitted to the intensive care units. DESIGN A prospective, observational cohort study conducted from 1 September 2010 to 1 March 2011. SETTING General intensive care unit (G-ICU) of a third level university hospital. PATIENTS OR PARTICIPANTS The study included patients on mechanical ventilation (MV) for over 12 hours, and who in the process of weaning were subjected to low-level pressure support. Exclusion criteria were age under 18 years, ventilation via tracheotomy and patients failing to cooperate for different reasons. During the study, 392 patients were admitted to the G-ICU; of these, 214 required MV. The weaning process was started in 154 cases. Fifty-four patients were excluded from the study, and 24 were not extubated from MV. A total of 76 patients were finally extubated and analyzed. VARIABLES OF INTEREST Vd/Vt was calculated as the ratio (PaCO(2)-Pє CO(2))/PaCO(2), with the recorded parameters. RESULTS Logistic regression analysis showed a significant association between the Vd/Vt and extubation failure, with OR=1.52 (95%CI 1.11 to 2.09, p=0.008). The area under the ROC curve with respect to the prediction of extubation failure according to the Vd/Vt value was 0.94 (95%CI 0.86 to 0.98, p<0.0001). CONCLUSIONS Vd/Vt is a powerful predictor of extubation failure in patients on MV.