D. Escudero Augusto

Diagnóstico clínico de muerte encefálica. Prerrequisitos y exploración neurológica

Para el medico intensivista, realizar un diagnosticode muerte encefalica (ME) implica tomar decisiones de gran responsabilidad: retirar las medidas de soporte, o valorar la donacion deorganos para trasplante. En este trabajo, se repasa el diagnostico de ME, centrandose fundamentalmente en sus aspectos clinicos e insistiendo en la necesidad de realizar una exploracion neurologica sistematica, completa y extremadamente rigurosa. Se detallan los prerrequisitos que ha de presenter el paciente antes de iniciar el protocolo diagnostico, y la exploracion neurologica necesariaincluyendo cada uno de los reflejos troncoencefalicosy la prueba de apnea. Tambien, serevisan las caracteristicas y tipos de actividadmotora de origen medular que pueden apareceren situaciones de ME, asi como el periodo de observacion necesario para realizar dicho diagnostico. In this paper, the diagnosis of BD is revised,focusing mainly on its clinical issues and insisting upon the necessity of obtaining a systemic, complete, and extremely accurate neurologic examination. Details are given of the pre-requisites that must be met by the patient before a diagnostic protocol is initiated and the necessary neurologicexamination including each of the brain stem reflexes and theapnea test. Also, the characteristicsand types of spinal cord motor activities are revised which may be present in situations of BD, as well as the required observation period to obtain such diagnosis.

Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury

Abstract Context Pressure ulcers are especially difficult to treat in patients with spinal cord injury (SCI) and recurrence rates are high. Prompted by encouraging results obtained using bone marrow stem cells to treat several diseases including chronic wounds, this study examines the use of autologous stem cells from bone marrow to promote the healing of pressure ulcers in patients with SCI. Objective To obtain preliminary data on the use of bone marrow mononuclear cells (BM-MNCs) to treat pressure ulcers in terms of clinical outcome, procedure safety, and treatment time. Participants Twenty-two patients with SCI (19 men, 3 women; mean age 56.41 years) with single type IV pressure ulcers of more than 4 months duration. Interventions By minimally invasive surgery, the ulcers were debrided and treated with BM-MNCs obtained by Ficoll density gradient separation of autologous bone marrow aspirates drawn from the iliac crest. Results In 19 patients (86.36%), the pressure ulcers treated with BM-MNCs had fully healed after a mean time of 21 days. The number of MNCs isolated was patient dependent, although similar clinical outcomes were observed in each case. Compared to conventional surgical treatment, mean intra-hospital stay was reduced from 85.16 to 43.06 days. Following treatment, 5 minutes of daily wound care was required per patient compared to 20 minutes for conventional surgery. During a mean follow-up of 19 months, none of the resolved ulcers recurred. Conclusions Our data indicate that cell therapy using autologous BM-MNCs could be an option to treat type IV pressure ulcers in patients with SCI, avoiding major surgical intervention.

Conclusiones de la III Conferencia de Consenso de la SEMICYUC. : Muerte encefálica en las Unidades de Cuidados Intensivos

Fundamento Las implicaciones asistenciales y sociales que la muerte encefalica tiene en el quehacer diario de los medicos que trabajan en las Unidades de Cuidados Intensivos justifican la realizacion de esta Conferencia de Consenso, con el objetivo de elaborar unas recomendaciones diagnosticas de muerte encefalica y de unificar los criterios de actuacion y la toma de decisiones clinicas Metodo El modelo de Conferencias de Consenso adoptado por la SEMICYUC se centra en intentar dar respuesta a unas preguntas predefinidas sobre el tema en cuestion, por parte de “expertos” que aportan las “pruebas” disponibles sobre cada pregunta concreta a un jurado no prejuzgado sobre la materia. Finalmente, el jurado elabora las conclusiones relativas a cada una de las preguntas formuladas Conclusiones Se presentan las conclusiones del jurado relativas a las dos preguntas claves: ?cuales son los criterios diagnosticos de muerte encefalica? y ?cuales son las implicaciones eticas del diagnostico de muerte encefalica y que decisiones clinicas debe tomar el medico intensivista tras dicho diagnostico?

Actualización en hemorragia cerebral espontánea

La hemorragia cerebral espontanea no aneurismatica o hemorragia intracraneal supone el 10-15% de todos los ictus y segun su localizacion puede ser intraparenquimatosa o intraventricular. Su localizacion mas frecuente es en los ganglios de la base, y la etiologia predominante es la hipertension arterial mal controlada. En Espana la incidencia asciende hasta los 15 casos por cada 100.000 habitantes/ano, siendo mas frecuente en varones mayores de 55 anos. La hemorragia intracranial es mucho menos frecuente que el ictus isquemico, pero presenta una mayor mortalidad y morbilidad, siendo una de las primeras causas de discapacidad grave. La hemorragia cerebral no es un fenomeno monofasico que ceda inmediatamente, ya que el hematoma continua aumentando en las primeras 24 horas. Por esta razon, y por las caracteristicas propias de la enfermedad, son pacientes graves que requieren ingreso en una Unidad de Cuidados Intensivos donde se debe rea lizar la estabilizacion hemodinamica y cardiorres piratoria, ademas de un estricto control del nivel de conciencia y el resto de parametros habituales de neuromonitorizacion. En el presente articulo se hace un repaso sobre la epidemiologia, fisiopatologia, presentacion clinica, diagnostico y las diferentes opciones terapeuticas, realizando una actualizacion sobre el tratamiento de las hemorragias intracraneales, tanto desde el punto de vista medico como quirurgico.

Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica

PURPOSE To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN Observational prospective study. SETTING Mixed ICU. Third level hospital. PATIENTS Sixty adult patients. Consecutive sample. INTERVENTIONS None. VARIABLES OF INTEREST Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke.