Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients.

Percutaneous tracheostomy is used primarily to assist weaning from mechanical ventilation in the intensive care unit. We report our experiences of 800 such procedures performed in the intensive care unit by a collaborative team (critical care and ENT specialists). Most procedures (85.6%) were performed by residents supervised by the intensive care unit staff. Complications occurred in 32 patients (4%). Intraprocedural complications occurred in 17 patients (2.1%), early postprocedural complications in six (0.75%), and late postprocedural complications in nine (1.1%). No deaths were directly related to percutaneous tracheostomy. The incidence of complications was greater in percutaneous tracheostomy performed by the residents during their initial five attempts compared to their later attempts (9.2% vs 2.6%, p < 0.05). The low incidence of complications indicates that bedside percutaneous tracheostomy can be performed safely as a routine procedure in daily care of intensive care unit patients.

Blood levels of cytokines in brain-dead patients: relationship with circulating hormones and acute-phase reactants.

We hypothesized that increased levels of blood cytokines occur in brain-dead patients, and that these cytokines are responsible for some of the endocrine and/or acute-phase reactant abnormalities found in these patients. We measured blood levels of cytokines, hormones, and acute-phase reactants in 18 brain-dead potential organ donors at the moment of establishing the legal diagnosis of brain death and compared them with levels found in a control group. Although interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) levels were within the normal range, interleukin-6 (IL-6) levels were clearly above the normal range in all patients (median, 1,444 pg/mL; range, 75 to 11,780). In the brain-dead group, total thyroxine (tT4), free T4 (fT4), triiodothyronine (T3), thyrotropin (TSH), dehydroepiandrosterone sulfate (DHEA-S), testosterone, albumin, Zn, and osteocalcin levels were decreased, T3 resin uptake index (T3 RUI), corticotropin (ACTH), cortisol, 11-deoxycortisol (11-DOC), 17-hydroxyprogesterone (17-OHPr), aldosterone, luteinizing hormone, and follicle-stimulating hormone levels were normal, and reverse T3 (rT3), renin, and C-reactive protein (CRP) levels were increased. Multiple regression analysis demonstrated significant interrelations between IL-6 and T4, T3, testosterone, and CRP. We also studied the evolution of some of these parameters in four patients with severe head injury who finally developed brain death. IL-6 levels on admission to the intensive care unit (ICU) were above the normal limits, as in other patients with cranial trauma, but when the patients developed brain death, there was a pronounced increase in IL-6 levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of post-splenectomy residual splenic function. Splenic autotransplants.

Splenectomy increases the risk of fulminant sepsis. The present study assesses residual splenic function in patients splenectomized due to traumatic rupture of the spleen; and six cases with splenic autotransplants. Splenic tissue was observed in only 48% of the splenectomized patients and 100% of the autotransplant cases. The two most reliable analytical parameters to assess the presence of functional splenic tissue, were the absence of Howell-Jolly bodies and normal IgM blood levels. In cases where total splenectomy is indicated, it has proved useful to perform autotransplantation of splenic tissue at omentum major level.

[Bronchial rupture in blunt thoracic trauma]. / Rotura bronquial en traumatismo torácico cerrado.

In closed chest trauma, bronchial rupture is an unusual but potentially serious complication, with an associated mortality rate of 30%. Recent decades have seen an increase in incidence parallel to greater use of transport. Eighty percent of injuries are located 2.5 cm from the carina. Diagnosis is based on clinical signs, imaging and bronchoscopy. Subcutaneous emphysema and respiratory insufficiency are the most common findings. Images show the presence of pneumothorax, pneumomediastinum or both. Bronchoscopy is the diagnostic method of choice and must be performed early. Treatment consists of reestablishing anatomical continuity of the tracheobronchial tree by surgical repair if the lesion affects more than a third of the circumference and/or pneumothorax is not resolved after two chest drainages. This type of injury should be recognized and treated early, both to restore lung function and to prevent associated complications caused by delay. However, initial findings are seldom specific, requiring the physician to display a high degree of suspicion and explaining why diagnosis often comes late.

[Chylothorax secondary to blunt thoracic trauma. Report of 6 cases]. / Quilotórax secundario a traumatismo torácico cerrado. A propósito de 6 casos.

Chylothorax is a rare condition that even more rarely arises as a result of closed thoracic trauma. We report a series of 6 patients who suffered chylothorax after closed trauma, who were diagnosed early and treated conservatively. Either total parenteral feeding or adjusted enteral feeding, depending with circumstances, was started early such that complications from chylothorax were few. Surgery was required in only one case, and outcomes were satisfactory in all patients, none of whom died.

[Traumatic bilateral chylothorax (author's transl)]. / Quilotórax bilateral traumático.

A case is presented of a bilateral chylothorax caused by rupture of the thoracic duct, secondary to a closed traumatism of the thorax in a polytraumatized patient, and produced by a mechanism of hyperextension of the dorsal segment of the vertebral column. Considerations are made with reference to the anatomy of the thoracic duct, the rupture mechanism, diagnosis, complications and treatment. The chylothorax could not be distinguished clinically and by simple radiology from the traumatic hemothorax. The preliminary diagnosis will be made according to the macroscopic appearance of the drained fluid, and the definite diagnosis by the analytical and histopathologic characteristics of the same fluid. The lymphographic examination reveals the exact point of the lesion. The immediate complications are related to the respiratory insufficiency due to the occupation of the pleural space, and under a long period of time undernutrition provoked by the loss of fats and proteins. The treatment of choice is based upon the early drainage of the chylothorax and on the absolute suppression of the oral intake, establishing a complete parenteral feeding during at least 15 days. Afterwards oral diet can be initiated with a gradual increase in its quantity and always without fat content, while at the same time the parenteral nutrition is reduced. Following this protocol a great number of ruptures of the thoracic duct can be corrected, achieving a spontaneous closure of the duct. In the cases in which this not occur, at the end of 15 days it would be advisable to perform a surgical operation according to the Lampson's ligature technique.

[Myocardial infarction due to buckshot lodged in the right coronary artery (author's transl)]. / Infarto de miocardio por perdigón alojado en arteria coronaria derecha.

A rare case of myocardial infarction produced by a buckshot lodged in the right coronary artery is presented. It resulted from a shotgun blast aimed at the right side of the chest. The patient was admitted to an Intensive Care Unit in a state of shock 1 hour after the accident. The diagnosis was suspected from the first moment because of ECG disturbances and it was later confirmed by coronary angiography. Hemodynamic studies were carried out simultaneously. The patient also presented hemothorax requiring pleural drainage. X-rays revealed a lung contusion with an intraparenchymatous hematoma the whole length of the projectile pathway. During the clinical course a slight hemopericardium was demonstrated by echocardiography; it was originally suspected on the basis of the X-rays. Drainage was not necessary. The patient left the Intensive Care Unit 7 days after entry and was discharged from the Hospital 5 days later. His clinical and hemodynamic condition was good and ECG indicate cicatrization of the myocardial infarction of the diaphragmatic face. The diagnosis and treatment of open or closed traumas of the thorax with similar cardiac involvement in emergency conditions are discussed. The authors prefer not to operate immediately in these cases.

[Extrahepatic biliary lesions in abdominal traumatism]. / Lesiones biliares extrahepáticas en el traumatismo abdominal.

The extrahepatic biliary tree traumatisms are rare and hard to diagnose; 15 of 864 patients with surgery treatment for abdominal trauma for over 19 years (1974-1992) were studied retrospectively. Twelve blunt abdominal traumas (9 traffic accident and 3 falls down) and 3 open traumas (stabbing in two and gunshot wounds in one case). Eleven had gallbladder injury, two gallbladder and biliary duct and two exclusively biliary duct. Only one case was an isolated lesion, in the rest of cases, intra or extra abdominal lesions, occasionally both, were seen. The diagnostic method, associated lesions, morbi-mortality are reviewed. Surgical treatment was cholecystectomy for gallbladder injury and direct suture with T-tube (Kehr) for biliary duct injury.

[The administration of 20 ppm of inhaled nitric oxide produces a faster response than the inhalation of 5 ppm in adult respiratory distress syndrome]. / La administración de 20 ppm de óxido nítrico inhalado produce una respuesta más rápida que la inhalación de 5 ppm en el síndrome de distrés respiratorio del adulto.

OBJECTIVES: To compare the effects of 5 and 20 ppm of nitric oxide, evaluating time until response for each dose, in patients with adult respiratory distress syndrome (ARDS). PATIENTS AND METHODS: The study was prospective, controlled and random. Fifteen patients assigned to two groups received either 5 ppm (8 patients) or 20 ppm (7 patients) from November 96 to July 97. The main variables analyzed were PaO2/FiO2 and pulmonary vascular resistance index. We also studied etiology, severity of pulmonary damage as reflected by the Lung Injury Score, age, sex, Apache II prognostic score and exitus. Outcome was considered good if PaO2/FiO2 increased and/or pulmonary vascular resistance index decreased by more than 30% from the initial level (before inhalation of nitric oxide). RESULTS: The mean lung injury score was 2.9 +/- 0.4 and the two groups were homogeneous. Time until response to nitric oxide was significantly less in the 20 ppm group. Both PaO2/FiO2 and pulmonary vascular resistance index improved significantly in both groups whereas Qs/Qt improved only in the 20 ppm group. We also found that cardiac index and oxygen transport increased, the latter significantly only in the 20 ppm group. NO2 formation was less than 2 ppm and methemoglobin levels did not rise above 2%. CONCLUSIONS: Inhaled nitric oxide significantly improves oxygenation and decreases pulmonary vascular resistance without altering systemic vascular resistance during treatment of ARDS. The final outcomes were similar for both doses, but the 20 ppm dose produced a significantly faster response as well as a significant decrease in Qs/Qt.

[Traumatic dissection of the internal carotid artery by a safety belt: a report of two cases]. / Disección traumática de la arteria carótida interna por el cinturón de seguridad: descripción de dos casos.

Traumatic internal carotid artery dissection secondary to blunt trauma is a rare event accounting for 0.08 to 0.4% of all traumatic lesions. The spectrum of traumatic lesions that can affect the internal carotid artery includes minor lesions like spasm, intimal tears, or mural contusions and serious lesions like pseudoaneurysms and complete occlusion. Delayed clinical presentation is typical and can include headache, hemiparesis, partial Horner's syndrome, and cranial nerve palsy. Embolization secondary to the dissection can have devastating effects because it may cause ischemic stroke. Traumatic internal carotid artery dissection after safety belt trauma is very rare; it is usually due to direct cervical trauma on the side of the shoulder fixation point, which causes external bruising along the pathway of the safety belt. We present two cases of traumatic internal carotid artery dissection with concomitant cerebral infarcts caused by safety belts; we discuss the clinical, diagnostic, and therapeutic aspects of this lesion.