Eduardo Tobar A

Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica

Small intestine bacterial overgrowth in patients with chronic pancreatitis Background: Previous reports describe 30-40% of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64%), recurrent abdominal pain in 8 (57%), intermittent diarrhea in 5 (36%) and steatorrhea in 5 (36%). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92%) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography. Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of life (Rev Med Chile 2008; 136: 976-80). (Key words: Gastrointestinal contents; Malabsorption syndrome; Pancreatitis, chronic)

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal

g/g) in 10 (14%) and severely decreased in 13(19%). There was a significant association between elastase levels and time of evolution ofdiabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit(p=0.042). No significant association was found between elastase levels and other chroniccomplications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy orwith insulin requirement.

Sedación guiada por protocolo versus manejo convencional en pacientes críticos en ventilación mecánica

Background: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. Aun: To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). Material and methods: Inclusion criteria was the need of MV more than 48 h. The exclusion criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. Results: Forty patients were included, 22 aged 65±19 years in group P and 18 aged 54±21 years in group C. Apache II scores were 16±8 and 19±8 in each group. SAS score was more frequently evaluated within goal boundaries in group P than in group C (44% and 32%, respectively p =0.001). No differences in the proportion of patients with inadequate sedation were observed between treatment groups. Midazolam doses were lower in P than in C group (0.04 (0.02-0.07) and 0.06 (0.03-0.08) mg/kg/h respectively, p =0.005). Conclusions: The implementation of sedation protocol applied by nurses improved the quality of sedation and reduced the doses of Midazolam in mechanically ventilated patients

Candidiasis invasoras en el paciente crítico adulto

Las infecciones invasoras por Candida spp, representan una patologia relevante en los pacientes criticos. Para su oportuno diagnostico es necesaria una elevada sospecha clinica, tomando en consideracion el cuadro clinico y la presencia de factores de riesgo. Pese a la incorporacion de nuevos farmacos al arsenal terapeutico durante la ultima decada, mantiene una elevada mortalidad. Las claves para mejorar los desenlaces clinicos en estos pacientes son el empleo de una terapia precoz, eficaz y que permita la cobertura de distintas especies de Candida: C albicans y no albicans. Recientes guias internacionales sugieren la terapia empirica con equinocandinas ante la sospecha de candidiasis invasora en esta poblacion de pacientes. Este grupo de farmacos ha documentado adecuada eficacia clinica y seguridad en estos pacientes. Se espera que la incorporacion de nuevas equinocandinas al mercado aminore sus costos y mejore el acceso a este grupo de farmacos.

Traqueostomía percutánea con asistencia fibrobroncoscópica: Evaluación prospectiva de 100 casos consecutivos y revisión de la literatura

7 days of mechanical ventilation before PT. Eight patients (8%) had operativecomplications. One had an episode of transitory desaturation, one had a transitory hypotensionrelated to sedation and six had mild bleeding not requiring transfusion. No patient requiredconversion to surgical tracheostomy. Four patients (4%) presented post operative complications. Twohad a mild and transitory bleeding of the ostomy, and two had a displacement of the cannula. Noother complications were observed.

Hepatitis crónica por virus C: factores asociados a la severidad del daño histológico

Background: Twenty percent of patients with chronic hepatitis C evolve to cirrhosis in 10 to 20 years. The degree of steatosis and hepatic iron stores in liver biopsy increase the risk. Age, high body mass index, diabetes mellitus and alcohol consumption are factors associated to the severity of liver damage. Aim: To study the association of steatosis and increased iron stores in the liver biopsy and age, overweight, alcohol consumption and diabetes with the severity of liver damage in patients with hepatitis C virus infection. Patients and methods: Retrospective study of 84 liver biopsies of patients with chronic infection with hepatitis C virus were studied. The pathological appearance was classified as stage I when chronic hepatitis with mild activity without fibrosis was observed; as stage II when moderate chronic hepatitis with mild fibrosis was observed and as stage III when there was a moderate chronic hepatitis with fibrosis or cirrhosis. The amount of steatosis and iron deposition in the biopsy were also assessed. Results: Forty one percent of patients were in stage I, 32% in stage II and 27% in stage III. Patients in stage I were younger than those in stages II and III (40.7 and 52.2 years respectively, p <0,001). No association between the severity of liver damage and the degree of steatosis, hemosiderosis, body mass index or alcohol intake, was observed. The frecuency of diabetes mellitus increased along with pathological staging (3, 15 and 30% in stages I, II and III, respectively, p <0,05). Conclusions: This study confirms that severity of chronic hepatitis C is associated with age and the presence of diabetes mellitus (Rev Med Chile

Delirium postoperatorio: Una ventana hacia una mejoría de la calidad y seguridad en la atención de pacientes quirúrgicos

El delirium postoperatorio constituye una complicacion frecuente y relevante de los pacientes quirurgicos, en particular en los adultos mayoRes Su genesis es multifactorial participando caracteristicas preexistentes del paciente, y gatillantes como medicamentos, dolor, el enfrentamiento anestesico peri operatorio y la intensidad de la respuesta inflamatoria asociada al trauma quirurgico, entre otros. La aparicion de delirium postoperatorio se asocia a desenlaces adversos, como una mayor estadia hospitalaria, mayor riesgo de complicaciones, y a una reduccion en la funcionalidad y el estado cognitivo en la evolucion alejada. Estrategias de prevencion no farmacologicas multimodales, han documentado una reduccion significativa en la incidencia de delirium. La terapia del delirium, debe enfocarse en la busqueda y manejo de factores precipitantes, en favorecer un adecuado entorno no farmacologico, y en el uso apropiado de neurolepticos. El adecuado reconocimiento de esta entidad, y la implementacion de estrategias de prevencion no farmacologicas constituyen actualmente un estandar que promueve una atencion de calidad y segura a los pacientes quirurgicos.

Medicina intensiva en Chile: desafíos para su desarrollo. Documento de la Comisión Nacional de Medicina Intensiva del Ministerio de Salud

Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline.