Eduardo Miñambres

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.

Impact of restrictive fluid balance focused to increase lung procurement on renal function after kidney transplantation

BACKGROUND Restrictive management of fluid status has been proposed to increase the rates of lung grafts available for transplant. However, no studies have supported the effect of this negative fluid balance in the kidney graft recipients. METHODS We evaluated the effect of restrictive fluid balance in brain-dead donors and their impact in 404 kidney recipients using Kaplan-Meier curves and Cox regression for long-term effects, and logistic regression for short-term effects. Our primary interest was graft survival and the second was occurrence of delayed graft function (DGF). RESULTS A negative or equalized fluid balance with a central venous pressure (CVP) <6 mm Hg affects neither graft survival in kidney recipients (P = 0.983) nor the development of DGF (P = 0.573). A positive fluid balance between brain death and organ retrieval does not reduce either the risk of graft survival or the risk of DGF. CONCLUSION We concluded that restrictive management of fluid balance in a multiorgan donor supports adequate perfusion to vital organ systems even with a CVP <6 mm Hg. A strict fluid balance could avoid volume overload and lung neurogenic oedema, increasing the rate of lung grafts available for transplant without impacting either kidney graft survival or DGF development.

Effect of an intensive lung donor-management protocol on lung transplantation outcomes.

BACKGROUND An intensive lung donor-management protocol based on a strict protocol would increase the lung procurement rate. The aim of this study was to determine the effect of such a protocol on the rate of lung grafts available for transplant. METHODS A lung-management protocol for donors after brain death (DBD) was implemented in 2009. Lung donors from 2009 to 2011 were the prospective cohort, and those from 2003 to 2008 formed the historical control. We analyzed the synergic effect of several measures, such as protective ventilation, ventilator recruitment maneuvers, high positive end-expiratory pressure, fluid restriction with reduced extravascular lung water values, and hormonal resuscitation therapy in multiorgan DBD. The number of lungs available for transplantation was the main outcome measure. For recipients, early survival and the rate of primary graft dysfunction (PGD) grade 3 were the main outcome measures. RESULTS The DBD rate was more than 40 donors per 1 million population in both periods. The rate of lung donors increased from 20.1% to 50% (p < 0.001), quadrupling the number of lung donors (p < 0.001), grafts retrieved (p = 0.02), and patients who received a lung transplant (p < 0.01). No differences were observed in the survival of early recipients (p = 0.203) or in the rate of PGD grade 3 (p = 0.835). CONCLUSION The management of multiorgan DBDs should be approached as a global treatment requiring attentive bedside management. Implementing an intensive lung donor-management protocol based on synergic measures increases lung procurement rates, negative effect on early survival of lung recipients or PGD grade 3.

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.

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.

Neumonía varicelosa en adultos: 30 casos

Objectives: During the past 10 years, 30 adults (age > 15 years) were treated for varicella pneumonia in our centre. Methods: There were 16 males and 14 females. Ages ranged from 15 to 58 years (mean, 32.73±7.67 years). Twenty-seven patients (90%) were nonpregnant adult smokers and three patients (10%) were pregnant women. The hospital stay ranged from 4 to 57 days (mean, 14.96±12.02 days). Results: Seven patients (23.3%) were managed in the intensive care unit and two patients (6,6%) required mechanical ventilation. The most common radiographic findings were interstitial infiltrates in twenty-one patients (70%) and interstitial-alveolar infiltrates in seven patients (23.3%). Physical examination of the chest did not reveal abnormalities in twenty patients (66,6%). Fifteen patients (50%) were severely hipoxic with pO2/FiO2 ratio less than 300. Twelve patients (40%) presented thrombocytopenia and fifteen (50%) presented hyponatremia. The most frequent clinical features included: fever (100%), dry cough (86.6%), dysnea (66.6%) and chest pain (50%). One patient (3.3%) died. Three patients (10%) developed asthma and one other patient developed pulmonary fibrosis. Conclusions: Smoking is associated with an increase incidence of varicella pneumonia in adults. A chest x-ray should be practised in all cases of varicella in adults and they all should also be admitted to hospital. Intravenous aciclovir is recommended for treatment of varicella pneumonia in adults and in seriously ill patients the association of corticosteroids should be considered.

Aggressive lung donor management increases graft procurement without increasing renal graft loss after transplantation

To determine the impact of an aggressive protocol on the rate of lung grafts available for transplant. We analyzed the impact of this management on kidney graft survival after kidney transplantation.

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.