Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

Emerging and imported diseases diagnosed in the emergency department of a hospital in Madrid. / Enfermedades emergentes e importadas diagnosticadas en el servicio de urgencias de un hospital de Madrid.

OBJECTIVES: To describe the clinical and epidemiologic characteristics of patients diagnosed with malaria, dengue fever, and Zika or chikungunya virus infections in a hospital emergency department. To describe the usefulness of the department's diagnostic resources. MATERIAL AND METHODS: Descriptive observational study of patients diagnosed with infectious tropical diseases on the basis of samples collected in the emergency department. RESULTS: The department diagnosed 4 cases of dengue fever, 7 cases of Zika virus infection, 7 of malaria, and 2 concomitant infections (malaria plus dengue fever and malaria plus chikungunya infection). CONCLUSION: Most patients with these infections were males and natives of areas where the diseases were endemic. Even when malaria is diagnosed early, the possibility of concomitant infection by other arboviruses must be ruled out. Serology is necessary to rule out Zika virus infection; polymerase chain reaction testing of urine and serum should be included.

OBJETIVO: Describir las características clínicas y epidemiológicas de los pacientes diagnosticados de malaria, dengue, zika y chikungunya en un servicio de urgencias hospitalario (SUH), así como el valor de diagnóstico de las técnicas de las que se disponen en el SUH. METODO: . Estudio descriptivo, observacional, en el que se incluyeron pacientes diagnosticados de enfermedades infecciosas tropicales a partir de pruebas solicitadas desde un SUH. RESULTADOS: Se diagnosticaron cuatro casos de dengue, siete casos de zika, tres casos de malaria y dos casos de coinfección (malaria + dengue y malaria + chikungunya). CONCLUSIONES: . La mayoría de los pacientes valorados son varones, nativos de zonas endémicas. Aunque se realice un diagnóstico precoz de malaria, es necesario descartar coinfección por distintos arbovirus. Para estudio de virus zika, hay que solicitar una prueba de PCR en orina, además de serología y PCR en suero.

Compresión medular por sarcoma granulocítico primario / Spinal cord compression due to nonleukemic granulocytic sarcoma

El sarcoma granulocítico (SG) es una lesión poco frecuente asociada a síndromes mielodisplásicos, mieloproliferativos o leucemias, aunque puede ser el primer hallazgo en un paciente previamente sano. Presentamos un SG que comenzó como compresión medular, en un paciente sin patología hematológica previa. Las imágenes radiológicas demostraron una lesión lítica en L1 que precisó cirugía urgente. Fue preciso realizar inmunohistoquímica de la muestra para llegar al diagnóstico. El aspirado medular no mostró evidencia de patología hematológica, siendo el SG la primera manifestación. El paciente recibió posteriormente tratamiento con quimioterapia y radioterapia, falleciendo 20 meses después del diagnóstico de una sepsis Pseudomonas aeruginosa intratratamiento de una leucemia mieloblástica. En resumen, el SG primario es un tumor infrecuente de difícil diagnóstico. Es necesario tener un alto grado de sospecha y solicitar amplios estudios inmunohistoquímicos para un diagnóstico correcto. El tratamiento debe ser precoz, agresivo e individualizado, ya que tiene mal pronóstico.

Granulocytic sarcoma (GS) is an infrequent lesion associated with myelodysplastic or myeloproliferative disorders or leukemia, although it may be the first finding in an otherwise healthy patient. A case of GS is described that presented as spinal cord compression, in a patient with no underlying hematological disorder. Imaging studies disclosed a single lytic lesion in L1, which required emergency surgery. Immunohistochemical staining of the surgical biopsy sample was needed for diagnosis. Bone marrow aspirate was unremarkable. The patient received chemo-radiotherapy, dying 20 months after diagnosis of Pseudomonas aeruginosa sepsis during treatment of acute myelogenous leukemia. In short, primary GS is an infrequent and difficult to diagnose tumor. A high degree of suspicion, along with extensive immunohistochemical studies are necessary for diagnosis. Treatment should be prompt, aggressive and individualized, since the prognosis is very poor.

Fever due to inflammation in acute aortic dissection: Description and proposals for diagnostic and therapeutic management.

Few studies have investigated fever secondary to underlying acute aortic dissection. A retrospective analysis of 59 patients was carried out. Diagnostic criteria for fever secondary to underlying aortic dissection were defined. Five patients had a clinical presentation consistent with inflammatory fever due to acute aortic dissection. The main features were: fever occurred within the first 48 hours, the variability in body temperature was significantly less than with infectious fever (P=.015), episodes of fever did not affect the patient's general clinical condition, microbiological tests gave negative results, there was no response to empirical antimicrobial treatment, and fever disappeared within 24 hours in those treated with indomethacin. In conclusion, fever due to acute aortic dissection has distinct characteristics that enable it to be distinguished from infectious fever. Good management of this condition should not involve unnecessary diagnostic tests, the inappropriate use of antimicrobials, or a delay in applying the therapeutic measures necessary to treat the underlying aortic dissection.