Luis Rucabado-Aguilar

Estancia media y pronóstico en la angina inestable: resultados del registro ARIAM

Fundamento y objetivo: El proposito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC). Pacientes y metodo: Estudio de cohorte retrospectivo que incluyo a los pacientes del registro espanol ARIAM (Analisis del Retraso en el Infarto Agudo de Miocardio). El periodo de estudio comprendio de junio de 1996 a diciembre de 2003. Su seguimiento se limito a UCI/UCC. Se realizo un analisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron ademas 3 analisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realizacion de intervencion coronaria percutanea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC. Resultados: Se incluyo a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asocio a la clase Killip, edad, necesidad de reanimacion cardiopulmonar y presencia de shock cardiogenico, arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizo ICP solo a 1.226 (8,9%) pacientes, aunque su realizacion se incremento con los anos. La ICP se asocio a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogenico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviacion estandar) fue de 3,15 (18,65) dias. La estancia media prolongada dependio de la edad, haber sido sometido a una coronariografia o ICP, clase Killip, ecocardiografia o ventilacion mecanica y presentar complicaciones graves. Conclusiones: La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una poblacion menos grave, y su realizacion con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocardica y a la ICP.

Myocardial dysfunction in the critically ill patient: Is it really reversible?

a Intensive Care Unit, Critical Care and Emergency Department, Medical-Surgical University Hospital of the Jaen Hospital Complex, and Jaen University, Jaen, Spain b Intensive Care Unit, Critical Care and Emergency Department, Puerto Real University Hospital, Cadiz, Spain c Departamento de Ciencias de la Salud, Universidad de Jaen, Spain d Intensive Care Unit, Critical Care and Emergency Department, Torrecardenas Hospital Complex, Almeria, Spain

Giant right atrial thrombi treated with thrombolysis.

The present report describes giant atrial thrombi that were treated with thrombolysis in a community hospital. Two patients with giant atrial thrombi whose treatment involved complications are presented. Both patients developed cardiogenic shock and were treated unsuccessfully with thrombolysis. Because thrombolysis of giant thrombi may be ineffective, patients in this situation may require surgery.

Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben?

La formación de los médicos residentes en las Unidades de Cuidados Intensivos (UCI) persigue prepararlos para una buena práctica clínica basada en el trabajo en equipo multidisciplinar; así mismo promueve la investigación, enseña a trabajar dentro de las dimensiones del profesionalismo, entrena en una buena comunicación en cualquier circunstancia y enseña a gestionar con calidad los recursos que dependan de ellos [1,2]. Paralelamente, la necesidad del reciclaje permanente para adaptarse a escenarios cambiantes hace que el autoaprendizaje y el pensamiento crítico sean imprescindibles en su Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben?

Evaluation of the performance of echocardiography in acute coronary syndrome patients during their stay in coronary units

Objectives: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU). Methods: Retrospective cohort study including all patients diagnosed with acute coronary syndrome—unstable angina (UA), acute myocardial infarction (AMI)—included in the ‘ARIAM’ Spanish multi-centre register. The study period was from June 1996 to December 2005. The follow-up period is limited to the time of stay in the Intensive Care Units or Coronary Care Units (ICUs/CCUs). A univariate analysis was carried out on the patients with UA and AMI according to whether or not echocardiograms were performed during their stay in ICU/CCU. In addition the data was evaluated for any temporal variation in the performance of echocardiography, and two multivariate analyses were carried out to evaluate the factors associated with performance of echocardiography in UA and AMI patients. Results: The study period included 45 688 AMI patients and 17 277 UA patients. Echocardiograms were performed in 26.87% AMI patients and 16.75% UA patients. In total, 15 172 echocardiograms were performed in ACS patients (23.6%). The multivariate analysis demonstrated that the variables associated with the performance of echocardiography in UA were: Killip and Kimball class, cigarette smoking, family history of cardiovascular events, cardiogenic shock, uncontrolled angina, mechanical ventilation and treatment with ACE inhibitors, while the presence of previous AMI was associated with fewer echocardiograms being performed. In AMI, the multivariate analysis showed the following variables to be associated with the performance of echocardiography: Killip and Kimball class, Q-AMI, right heart failure, the need for insertion of Swan-Ganz catheter, cardiogenic shock, high-degree AV block and the administration of ACE inhibitors, while age was associated with fewer being performed. Over the 10 years of the study period, there was a discrete but significant increase in the use of echocardiography in patients in ICU/CCU. Conclusions: Echocardiography is not commonly used in ACS patients while in ICU/CCU. UA and AMI patients who did have echocardiograms during their stay in ICU/CCU were chiefly those presenting heart failure and major complications, and represent a subpopulation with poor prognosis. The performance of echocardiography in ACS patients increased slightly over the length of their stay in ICU/CCU.

Septic shock secondary to infection of a left ventricular thrombus

We report the case of a 45-year-old woman who developed severe shock with multiorgan failure requiring admission to intensive care. Endomyocardial biopsy was performed and she was diagnosed with sepsis secondary to left ventricular thrombus abscess. Surgery was contraindicated and the patient received exclusively medical treatment; the clinical course was satisfactory and the patient is alive one year later. An apical thrombus may rarely be complicated by infection. Although management normally requires surgical excision, medical management may be effective in situations in which surgery is contraindicated.

Successful administration of alteplase in a venous thromboembolism crossing through a patent foramen ovale

We describe a case report observed via an echocardiography of a venous thromboembolism (VTE) that crosses through the patent foramen ovale to the left atrium and is successfully treated with alteplase. This is a case report of a tertiary care hospital without cardiac surgery facilities. An 81-year-old female seeking medical attention for dyspnoea, arriving at hospital with hypoxaemia, hypotension and prerenal failure. A computed tomographic (CT) pulmonary angiography was carried out, revealing a VTE. A transesophageal echocardiography (TEE) was carried out, exposing emboli in the right cavities, said thrombus crossing through the patent foramen ovale to the left atrium. A systemic thrombolysis is carried out using alteplase which improves the patients condition and results in the disappearance of thrombotic images in the various cardiac cavities. The evolution is positive and there is no evidence of embolic or haemorrhagic complications. When a paradoxical embolism is present, in the context of a serious VTE, carrying out thrombolysis could be a therapeutic option.

Administration of intrapericardial tissue adhesive after cardiac rupture and cardiac tamponade

OBJECTIVE To describe a series of patients treated with intrapericardial glue. DESIGN Case reports. Descriptive study. PATIENTS We describe the results obtained using the injection of a surgical intrapericardial adhesive in 19 patients who presented cardiac tamponade and shock after cardiac rupture. The technique was done using puncture and echocardiographic subxiphoid control. At the one-year follow-up, 5 patients had survived, with neither pseudoaneurysms nor constriction. One patient was injected with said adhesive in the right ventricular cavity. CONCLUSIONS Pericardial drainage, followed by the administration of intrapericardial glue may be an attractive technique. This technique should be studied for its possible utility when faced with surgical impossibility.

Chronotropic incompetence or tachycardiomyopathy as trigger of myocardial dysfunction in critically ill patients

a Intensive Care Unit, Critical Care and Emergency Department, Puerto Real University Hospital, Cádiz, Spain b Intensive Care Unit, Critical Care and Emergency Department, Medical–Surgical University Hospital of the Jaén Hospital Complex, and Jaén University, Jaén, Spain c Departamento de Ciencias de la Salud, Universidad de Jaén, Spain d Intensive Care Unit, Critical Care and Emergency Department, Torrecárdenas Hospital Complex, Almería, Spain

Bloqueo auriculoventricular en la angina inestable: Resultados del registro ARIAM

Objective. Describe the frequency of high degree atrioventricular block (HDAVB) in patients with unstable angina (UA), analyze the variables associated with their appearance and evaluate whether HDAVB is independently associated with increased mortality or increased length of ICU stay. Design. Retrospective descriptive study of patients with UA included in the ARIAM registry. Setting. ICUs from 129 hospitals in Spain. Patients. From June 1996 to December 2003 a total of 14,096 patients were included in the ARIAM registry with a diagnosis of UA. Main variables of interest. Variables associated with the development of HDAVB, variables associated with the mortality of patients with UA, variables associated with the length of ICU stay of patients with UA. Results. HDAVB frequency was 1%. Development of HDAVB was independently associated with the Killip classification and the presence of sustained ventricular tachycardia or ventricular fibrillation. Crude mortality of patients was significantly increased when HDAVB was present (9% versus 1%, p < 0,001). When adjusted for other variables, HDAVB was not associated with increased mortality. Development of HDAVB in patients with UA was independently associated with an increase in the length of ICU stay (adjusted odds ratio 1.89: 95% confidence interval: 1.33-5.69). Conclusions. Patients with UA complicated with HDAVB represent a high-risk population with an increased ICU stay.