Luis Castillo F

Craniectomía descompresiva en una paciente con encefalitis herpética asociada a hipertensión intracraneana refractaria

Herpetic encephalitis is the most common cause of viral encephali-tis in our country. Pathological studies show progressive necrosis and edema in specific territo-ries of the brain. The mortality of herpetic encephalitis was reduced from 70% to 20% with theuse of intravenous aciclovir in the first three days of illness. However, almost 50% of patientsdevelop a neurological deficit. One of the most important causes of death in herpetic encephali-tis is the refractory intracranial hypertension. There are anecdotal reports of patients with re-fractory intracranial hypertension due to herpetic encephalitis that were treated with decom-pressive craniectomy with good results. We report a 21 years old female patient with herpeticencephalitis and refractory intracranial hypertension that was successfully treated with a de-compressive craniectomy (Rev Med Chile 2003; 131: 1434-8).(

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.

Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media

Malignant middle cerebral territory infarction represents 5 to 10%of all brain infarctions. Its mortality is 80%, due to brain herniation and it is not reduced bymedical treatment. Decompressive hemicraniectomy reduces mortality to 12%, and thesubsequent quality of life of patients is acceptable. We report two male patients aged 61 and 54years, with a malignant middle cerebral territory infarction who were treated withdecompressive hemicraniectomy. After two years of follow up, both patients are self-sufficientand live at home with their families (Rev Med Chile 2005; 133: 447-52).(

Trombolisis intraarterial en trombosis de la arteria basilar: Recuperación de dos pacientes con síndrome de enclaustramiento

Locked-in syndrome is a dramatic clinical condition, the patient isawake, can listen and breath, but is unable to move any muscle, conserving only the vertical eyemovements. The most common cause of locked-in syndrome is the thrombosis of the basilar arteryand commonly leads to death, frequently due to pneumonia. Intravenous and intra arterialthrombolysis have been used successfully in a selective group of patients with ischemic stroke. Thereis only one report of two patients with locked-in syndrome who were treated successfully with intraarterial thrombolysis. Other authors, based in their experiences, do not recommend this treatment.We report two female patients aged 63 and 26 years, with Locked-in syndrome due to a basilarthrombosis who were treated successfully with intra arterial thrombolysis using ecombinant tissueplasminogen activator (r-TPA). The lapses between the onset of the symptoms and thrombolysis were5 and 8 hours respectively. A complete recanalization was obtained in both patients during thethrombolysis. One year after, the first patient has only a moderate ataxia, walking with assistanceand the other has a normal neurological examination (Rev Med Chile 2004; 132: 357-60 ).(Locked-in syndrome is a dramatic clinical condition, the patient is awake, can listen and breath, but is unable to move any muscle, conserving only the vertical eye movements. The most common cause of locked-in syndrome is the thrombosis of the basilar artery and commonly leads to death, frequently due to pneumonia. Intravenous and intra arterial thrombolysis have been used successfully in a selective group of patients with ischemic stroke. There is only one report of two patients with locked-in syndrome who were treated successfully with intra arterial thrombolysis. Other authors, based in their experiences, do not recommend this treatment. We report two female patients aged 63 and 26 years, with Locked-in syndrome due to a basilar thrombosis who were treated successfully with intra arterial thrombolysis using recombinant tissue plasminogen activator (r-TPA). The lapses between the onset of the symptoms and thrombolysis were 5 and 8 hours respectively. A complete recanalization was obtained in both patients during the thrombolysis. One year after, the first patient has only a moderate ataxia, walking with assistance and the other has a normal neurological examination.

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.

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)

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)

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.