Glenn Hernández P

Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: Primer estudio nacional multicéntrico

4. SS was the admission diagnosis of 94 of the 283 patients (33%)and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria(40%). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients.Global case-fatality ratio at 28 days was 15.9% (45/283). Case-fatality ratio in patients with orwithout SS at the moment of the survey was 26.7% (30/112) and 8.7% (17/171), respectively p<0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios forpatients with SS from Santiago and the other cities were similar, but APACHE II score wassignificantly higher in patients from Santiago. In SS patients, the independent predictors of mortalitywere SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SSpatients had a known sepsis focus (48% respiratory and 30% abdominal). Eighty five patients thatpresented SS after admission, had a respiratory focus.

Síndrome de respuesta inflamatoria sistémica severa: ¿es comparable a la sepsis severa?

Background: In 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions. Aim: To evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS. Patients and methods: Five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient. Results: One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48% in sepsis compared to 43 and 51% in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group. Conclusions: The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies.

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional

Background: The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign. Aim: To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation. Patients and methods: Prospective study of 77 patients (42 men, age 54±19 years, with 11±4 points of Glasgow coma scale (GCS), 61% with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index. Results: Thirty percent of patients died during follow up. Among surviving patients, 47% had a good recovery or moderate disability, and 74% had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis. Conclusions: Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients (Rev Med Chile 2004; 132: 11-8). (Key Words: Intensive care; Neurologic manifestations; Ventilators, mechanical)

Hipotermia intravascular inducida en el manejo de la hipertensión intracraneana en insuficiencia hepática aguda: Caso clínico

Acute liver failure has a mortality rate in excess of 80%. Most deaths are attributed to brain edema with intracranial hypertension and herniation of structures, where ammonium plays a major role in its generation. We report an 18 year-old female with a fulminant hepatic failure caused by virus A infection. The patient developed a profound sopor and required mechanical ventilation. A CT scan showed the presence of brain edema and intracranial hypertension. A Raudemic® catheter was inserted to measure intracranial pressure and brain temperature. Intracranial hypertension became refractory and intravascular hypothermia was started, reducing brain temperature to 33°C. Seventy two hours later, a liver transplantation was performed. After testing graft perfusion, rewarming was started, completing 122 hours of hypothermia at 33°C. The patient was discharged in good conditions after 69 days of hospitalization.

Evaluación de la microcirculación sublingual en un paciente en shock séptico refractario tratado con hemofiltración de alto volumen

Microcirculation is severely compromised in sepsis, with a reduction of capillary density and flow impairment. These alterations have important prognostic implications, being more severe in non-survivors to septic shock. Today microcirculation may be assessed bedside, non-invasively, using polarized light videomicroscopy, a technique known as SDF (side dark field). We report a 54 year-old man with an extramembranous nephropathy, that developed a necrotizing fascitis associated to septic shock, in whom microcirculation was periodically assessed during his management. The patient was treated with fluids, vasoactive drugs, antibiotics and was operated for exploration and debridement. As the patient persisted in refractory shock despite treatment, highvolume hemofiltration was started. Before hemofiltration the patient had severe microcirculatory alterations that improved during and after the procedure. Physiologic endpoints of high-volume hemofiltration in septic shock remain unknown, but it has the capacity to clear inflammatory mediators. Since microcirculatory alterations are in part secondary to these mediators, their removal is beneficial. Like other authors, we found no relation between microcirculation and other

Uso de anfotericina B en mezcla lipídica: ¿previene la toxicidad de la droga en pacientes críticos?

Background: Amphotericin B is efficacious for the treatment of systemic candidiasis, however it has potentially serious toxic effects. Administration as lipid emulsions has been advocated to decrease its toxicity. Aim: To compare the safety and tolerance of amphotericin B administered as lipid emulsion or dissolved in dextrose in water. Patients and methods: Forty five patients with confirmed or highly suspected systemic candidiasis were studied. Between January 1996 and June 1997 amphotericin B was administered in dextrose in water to 17 patients (group 1). Between July 1997 and December 1998, the drug was delivered in lipid emulsions (Intralipid, group 2). Clinical and laboratory parameters (serum creatinine, urea nitrogen and potassium), were assessed daily. Results: Both treatment groups were clinically comparable and had the same survival. Accumulative amphotericin B dose administered was 343.2 ± 197 and 414.6 ± 518 mg respectively. Hypokalemia was more frequent in group 2 (52 and 25 % respectively, p < 0.05). There were no differences in the outcome of renal function or other adverse reactions. Conclusions: Administration of amphotericin B as lipid emulsions did not reduce its toxicity in critical patients (Rev Med Chile 2000; 128: 1101-07)

Actualización del bundle de reanimación inicial y monitorización integral de la perfusión tisular en la sepsis severa

Sepsis is a global health problem. Despite recent advances in understanding its pathophysiology and clinical trials testing potential new therapies, mortality remains unacceptably high. In fact, sepsis is the leading cause of death in non-coronary intensive care units around the world. However, during the past decade, some studies have highlighted that early recognition of sepsis and an appropriate initial approach are fundamental determinants of prognosis. A systematic approach to the harmful triad of sepsis-related hypotension, tissue hypoperfusion and organ dysfunction, with low-cost, easy to implement, and effective interventions, can significantly improve the chances of survival. In this article, we will update the evidence supporting the initial resuscitation bundle for patients with severe sepsis, and discuss the physiological basis for perfusion monitoring during septic shock resuscitation.Sepsis is a global health problem. Despite recent advances in understanding its pathophysiology and clinical trials testing potential new therapies, mortality remains unacceptably high. In fact, sepsis is the leading cause of death in non-coronary intensive care units around the world. However, during the past decade, some studies have highlighted that early recognition of sepsis and an appropriate initial approach are fundamental determinants of prognosis. A systematic approach to the harmful triad of sepsis-related hypotension, tissue hypoperfusion and organ dysfunction, with low-cost, easy to implement, and effective interventions, can significantly improve the chances of survival. In this article, we will update the evidence supporting the initial resuscitation bundle for patients with severe sepsis, and discuss the physiological basis for perfusion monitoring during septic shock resuscitation.

Falla cardio-respiratoria severa tratada con asistencia cardiopulmonar extracorpórea: Caso clínico

Cardiopulmonary extracorporeal assistance is a high complexity procedure for patients with acute respiratory failure, who have failed conventional ventilatory support. A 30 years old female patient with bacterial endocarditis and congestive cardiac failure subjected to cardiac surgery presented severe hypoxemia, right heart failure and pulmonary hypertension, and failed conventional treatment. Cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) reverted the pathophysiologic alterations allowing a successful recovery (Rev Med Chile 2002; 130: 545-50)

Ventilación diferencial en el manejo del síndrome de distress respiratorio agudo secundario a mediastinitis necrotizante descendente: Rol de la tomografía axial computarizada dinámica de pulmón

Lung computed tomography (CT) is being used increasingly to assess lung morphology in patients on mechanical ventilation. Lung CT under known levels of airway pressure (dynamic CT) can also assess the response of lung parenchyma to ventilatory therapy. We report a patient with acute respiratory distress syndrome secondary to descending necrotizing mediastinitis, in whom lung dynamic CT oriented ventilatory management. Independent lung ventilation improved gas exchange and helped patient recovery (Rev Med Chile 2003; 131: 200-8)

Cateterización venosa suprahepática en cuatro casos de shock séptico severo: Report of four cases

Splanchnic hypoperfusion, with pathogenic implications for multiple organ failure, can occur during septic shock. We report four patients with septic shock in whom regional hepatosplenic splanchnic perfusion was monitored through suprahepatic vein catheterization and gastric tonometry. Suprahepatic lactate and oxygen saturation showed splanchnic hypoperfusion in all patients. These parameters improved only in the patient that survived. Gastric tonometry was more inconsistent. We conclude that suprahepatic vein catheterization could have a role in the management of septic shock. ( Rev Med Chile 2001; 129: 552-5)