Rodrigo Cornejo

Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy.

BACKGROUND The aim of this study was to determine the incidence of swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy (PDT) for prolonged mechanical ventilation (MV) and to compare the duration of the cannulation period and length of stay in the critical care unit (CCU) in patients with and without swallowing dysfunction. METHODS A total of 40 consecutive patients without neurologic disorders who require PDT for prolonged MV were included. Previous to the tracheostomy decannulation process, an otolaryngologist performed a fiberoptic endoscopic evaluation of swallowing (FEES). We used analysis of variance for the analysis; the results are presented as mean values +/- SD. RESULTS Mean age was 62 +/- 15 years. Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 21 +/- 2 and 9 +/- 1, respectively. Time of MV previous to PDT was 20 +/- 11 days, total MV duration was 38 +/- 16 days, and CCU stay was 63 +/- 27 days. The incidence of swallowing dysfunction in this group of patients was 38% (15/40). No difference was found in the age or time period of MV previous to PDT between groups. The time period between FEES to tracheostomy decannulation process was 19 +/- 11 days in patients with swallowing dysfunction vs 2 +/- 4 days in those patients without dysfunction (P < .001). Patients who developed swallowing dysfunction stayed longer in the CCU (69 +/- 23 vs 47 +/- 19 days, P < .01). CONCLUSIONS Nearly 40% of nonneurologic critically ill patients requiring PDT for prolonged MV presented swallowing dysfunction and experienced a significant delay in their tracheostomy decannulation process.

Higher than recommended amikacin loading doses achieve pharmacokinetic targets without associated toxicity

Antibiotic therapy improves the outcome of severe sepsis and septic shock, however pharmacokinetic properties are altered in this scenario. Amikacin (AMK) is an option to treat community or nosocomial infections, although standard doses might be insufficient in critically ill patients. The aim of this study was to evaluate two AMK dosage regimens in comparison with standard therapy with regard to efficacy in achieving adequate plasma levels as well as safety. In total, 99 patients with severe sepsis or septic shock were randomised to different AMK dose protocols: Group 1, 25 mg/kg/day; Group 2, 30 mg/kg/day; and Group 3, historical standard dose (15 mg/kg/day). Peak plasma concentrations at 1 h (C(max)) were determined. Pharmacokinetics was determined and renal function was monitored to evaluate toxicity. Groups were compared using bilateral T-test. Demographic characteristics of the three groups were comparable. AMK C(max) values were 57.4±9.8, 72.1±18.4 and 35.2±9.4 μg/mL, respectively (P<0.001 between Groups 1 and 2 versus Group 3, and P<0.01 between Group 1 versus Group 2). A C(max)>60 μg/mL was reached by 39%, 76% and 0% of patients in Groups 1, 2 and 3, respectively (P<0.001) and creatinine clearance at Day 28 was 95.6±47.4, 89.7±26.6 and 56.4±18.4 mL/min, respectively. In conclusion, a 30 mg/kg daily dose of AMK presents significantly higher C(max) compared with the other groups, with 76% of patients reaching recommended peak plasma levels with no association with higher nephrotoxicity. Standard doses are insufficient in critically ill patients to reach the recommended C(max).

Impact of emergency intubation on central venous oxygen saturation in critically ill patients: a multicenter observational study

IntroductionCentral venous oxygen saturation (ScvO2) has emerged as an important resuscitation goal for critically ill patients. Nevertheless, growing concerns about its limitations as a perfusion parameter have been expressed recently, including the uncommon finding of low ScvO2 values in patients in the intensive care unit (ICU). Emergency intubation may induce strong and eventually divergent effects on the physiologic determinants of oxygen transport (DO2) and oxygen consumption (VO2) and, thus, on ScvO2. Therefore, we conducted a study to determine the impact of emergency intubation on ScvO2.MethodsIn this prospective multicenter observational study, we included 103 septic and non-septic patients with a central venous catheter in place and in whom emergency intubation was required. A common intubation protocol was used and we evaluated several parameters including ScvO2 before and 15 minutes after emergency intubation. Statistical analysis included chi-square test and t test.ResultsScvO2 increased from 61.8 ± 12.6% to 68.9 ± 12.2%, with no difference between septic and non-septic patients. ScvO2 increased in 84 patients (81.6%) without correlation to changes in arterial oxygen saturation (SaO2). Seventy eight (75.7%) patients were intubated with ScvO2 less than 70% and 21 (26.9%) normalized the parameter after the intervention. Only patients with pre-intubation ScvO2 more than 70% failed to increase the parameter after intubation.ConclusionsScvO2 increases significantly in response to emergency intubation in the majority of septic and non-septic patients. When interpreting ScvO2 during early resuscitation, it is crucial to consider whether the patient has been recently intubated or is spontaneously breathing.

Fiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study

BACKGROUND Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy. OBJECTIVE The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients. PATIENTS AND METHOD A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m(2). RESULTS The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 +/- 9 kg/m(2) vs 22 +/- 3 kg/m(2) for the nonobese patient group (P < .001). The obese patients required 18 +/- 7 days of mechanical ventilation, on average, before PT vs 16 +/- 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2). CONCLUSION Percutaneous tracheostomy using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Extended prone position ventilation in severe acute respiratory distress syndrome: A pilot feasibility study

OBJECTIVES The aim of the study was to evaluate the safety of extended prone position ventilation (PPV) and its impact on respiratory function in patients with severe acute respiratory distress syndrome (ARDS). DESIGN This was a prospective interventional study. SETTING Patients were recruited from a mixed medical-surgical intensive care unit in a university hospital. PATIENTS Fifteen consecutive patients with severe ARDS, previously unresponsive to positive end-expiratory pressure adjustment, were treated with PPV. INTERVENTION Prone position ventilation for 48 hours or until the oxygenation index was 10 or less (extended PPV). RESULTS The elapsed time from the initiation of mechanical ventilation to pronation was 35 +/- 11 hours. Prone position ventilation was continuously maintained for 55 +/- 7 hours. Two patients developed grade II pressure ulcers of small extent. None of the patients experienced life-threatening complications or hemodynamic instability during the procedure. The patients showed a statistically significant improvement in Pao(2)/Fio(2) (92 +/- 12 vs 227 +/- 43, P < .0001) and oxygenation index (22 +/- 5 vs 8 +/- 2, P < .0001), reduction of PaCo(2) (54 +/- 9 vs 39 +/- 4, P < .0001) and plateau pressure (32 +/- 2 vs 27 +/- 3, P < .0001), and increment of the static compliance (21 +/- 3 vs 37 +/- 6, P < .0001) with extended PPV. All the parameters continued to improve significantly while they remained in prone position and did not change upon returning the patients to the supine position. CONCLUSIONS The results obtained suggest that extended PPV is safe and effective in patients with severe ARDS when it is carried out by a trained staff and within an established protocol. Extended PPV is emerging as an effective therapy in the rescue of patients from severe ARDS.

El clima escolar percibido por los alumnos de enseñanza media: Una investigación en algunos liceos de la Región Metropolitana

un espacio de convivencia conflictivo en las sociedades capitalistas modernas. Asimismo las caracteristicas que debe tener la ensenanza media, desde el punto de vista curricular y formativo, son objeto permanente de debate en distintas partes del mundo. Este fenomeno, a nuestro juicio, tiene su origen en las caracte-risticas mismas de la escuela como agente de socializacion (y por lo tanto tambien de reproduccion social) y las complejidades de la condi-cion juvenil en las sociedades modernas que han sido analizadas en repetidas ocasiones (cf. Cancino y Cornejo, 2001). Diversos estudios realizados en Chile, muchos de los cuales sirvieron de fundamento al actual proceso de reforma de la ensenanza media, nos muestran que nuestro pais no se escapa a esta realidad. Estos estudios hablan de una perdida de sentido de la ensenanza media

Successful response to intravenous immunoglobulin as rescue therapy in a patient with Hashimoto's encephalopathy

The authors describe the case of a 61-year-old woman who was admitted to our intensive care unit (ICU) due to impaired consciousness associated with generalised seizures. Her cerebrospinal fluid, electrolytes, acid-base analysis, and common laboratory and toxicology tests were normal. An MRI ruled out the presence of stroke or haemorrhage but showed severe leukoencephalopathy. Parkinsons disease, Creuzfeld–Jacob disease, vascular alterations, cancer, and rheumatological and metabolic diseases were evaluated and excluded. In view of her history of hypothyroidism despite adequate hormonal replacement and clinical behaviour, Hashimotos encephalopathy was considered. Anti-thyroperoxidase levels were above 3000 IU/ml. The patient received 5 g of methylprednisolone followed by prednisone, but after a favourable initial response, returned to a comatose state. However, after administration of intravenous immunoglobulin (IVIG) 2 g/kg, the patient recovered with resolution of neurological symptoms and was discharged from the ICU 4 days after finishing IVIG treatment.

Ser docente y subjetividad histórica en el Chile actual: discursos, prácticas y resistencias

El presente articulo da cuenta de una instancia de trabajo colectivo con profesores y profesoras de aula, el “Taller de Educadores Autores” (TEA), que tiene como proposito rastrear el proceso de construccion de nuevas subjetividades docentes que permitan dar cuenta de las actuales condiciones en que es desempenada la docencia, asi como proponer otras formas de ser docente. A traves del Taller, los profesores y profesoras problematizan acerca de los significados y sentidos de su trabajo por medio de la escritura de relatos de experiencias. En primer lugar, se situara el proceso de trabajo y subjetividad docente en el Chile actual. Luego, se explicitaran algunos aspectos fundamentales de los procedimientos y la metodologia que oriento el proceso colectivo de indagacion del TEA. Finalmente, se presentaran los principales hallazgos y resultados extraidos del analisis de las sesiones del proceso indagatorio.

High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock

Como Cornejo et al. observaram, essas duas tecnicas sao desafiadoras e necessitam de um ava-liacao caso a caso para tomada de decisao. Devem ser considerados os possiveis efeitos adversos dessas tecnicas. Uma metanalise mostra que “nao ha um efeito benefico global claro” quando se compara a hemofiltracao de alto volume com a hemofiltracao com volume padrao.We would like to discuss the publication “High-volume hemofiltration and prone ventilation”.(1) Cornejo et al. reported the use of the combination of these two novel approaches for the management of subarachnoid hemorrhage that is complicated by severe acute respiratory distress syndrome.(1) As Cornejo et al. noted, these two techniques are very challenging and require case by case decision making. There must be consideration of the possible adverse effects of these techniques. A meta-analysis shows that there is “no clear overall beneficial effect” when high-volume hemofiltration is compared to standard volume hemofiltration.(2) Some reports mention the adjustment of cytokine biological processes as the possible responsible factor, whereas other reports do not agree with that hypothesis.(2) In the present case report by Cornejo et al., the reason for the occurrence of septic shock remains unclear. Based on the patient’s available history, it seems that there is no laboratory confirmation of sepsis. Additionally, there is no evidence of cytokine biological process adjustment reported in the present article. In general, due to the uncertainties about the exact biological effect of high-volume hemofiltration, the beneficial effects of this procedure remain unconfirmed in septic shock.(3) Regarding prone positioning, the complication and side effect of the procedure can still be observed.(4) Cardiac arrest immediately after prone positioning is also reported.(5) In the present case report, the use of prone positioning might be valid, and the success of cardiac monitoring is established. Interestingly, 72 hours of prone positioning were required for adjustment of the pressure. This long period might be sufficient for self-adjustment of the patient’s intracranial pressure, due to the neurological improvement after manipulation or other additional procedures for the management of pressure, without the need of a special positioning procedure. The improvement of the patient might be due to the successful control of the neurological problem and might not be related to the use of high-volume hemofiltration plus prone positioning.

Hemofiltração de alto volume e ventilação em posição prona em hemorragia subaracnóidea complicada por grave síndrome do desconforto respiratório agudo e choque séptico refratário.

Relatamos o tratamento bem-suce- dido de dois pacientes com hemorragia subaracnoidea complicada com grave falencia respiratoria e choque septico refratario, utilizando, simultaneamente, ventilacao em posicao prona e hemofil - tracao de alto volume. Esses tratamentos de resgate permitiram que os pacientes superassem a grave situacao sem com- plicacoes associadas ou efeitos deleterios na pressao intracraniana e de perfusao cerebral. A ventilacao em posicao pro- na e, hoje, um tratamento aceito para sindrome de desconforto respiratorio agudo grave, e a hemofiltracao de alto volume e um suporte hemodinâmico nao convencional, que tem diversosWe report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team.