[Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome]. / Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida.

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.

[Assessment of neurologic function and complications in a retrospective cohort of patients with acute spinal cord injury due to trauma treated with large-dose methylprednisolone]. / Evaluación de la lesión neurológica y complicaciones médicas en una cohorte histórica de pacientes con lesión medular aguda traumática tras tratamiento con megadosis de metilprednisolona.

BACKGROUND AND OBJECTIVE: Methylprednisolone was used to improve neurologic recovery from spinal cord injury in the National Acute Spinal Cord Injury Studies (NASCIS). Debate over this use led to further research and a 2002 report stating that there was insufficient evidence to support this application as a standard therapy. Our aim was to retrospectively assess this application in a cohort of patients with spinal cord injury. METHODS: Retrospective cohort study of patients admitted to the intensive care unit (ICU) between 1997 and 2007 with a diagnosis of spinal cord injury due to trauma. The patients were grouped according to medical treatment received into a methylprednisolone group and a no-methylprednisolone group. We assessed change in neurologic function on the impairment scale of the American Spinal Injury Association on ICU admission and on discharge. We also recorded medical complications in each group. Cox multiple regression analysis was used to analyze differences between treatments. RESULTS: No significant differences were detected in neurologic outcome on discharge from the ICU (odds ratio [OR], 1.57; 95% confidence interval [CI], 0.69-3.54). The methylprednisolone-treated patients had more medical complications such as hyperglycemia (OR, 5.67; 95% CI, 1.85-17.31) or gastrointestinal bleeding (OR, 19.16; 95% CI, 1.64-223.30) than the patients who did not receive methylprednisolone. CONCLUSIONS: In this retrospective study, methylprednisolone was unrelated to improvement in neurologic outcome after acute spinal cord injury on ICU discharge although the patients treated with this drug were at greater risk of metabolic complications.

[Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit]. / Incidencia de las neumonías nosocomiales precoces y tardías asociadas a ventilación mecánica en una unidad de reanimación- críticos polivalente.

OBJECTIVES: To ascertain the frequency, risk factors, and causes of early- and late-onset ventilator-associated pneumonia (VAP) in a postanesthesia and critical care unit. MATERIAL AND METHODS: A prospective study was carried out between January 1, 1996 and December 31, 2001 of all ventilated patients staying longer than 48 hours in the critical care unit, with follow-up for 48 hours following discharge from the unit. Descriptive statistics were compiled for episodes of early- and late-onset VAP for a period of up to 4 days after intubation; univariate and multiple variable Cox regression analyses were also carried out. RESULTS: A total of 3614 patients were admitted to the unit (study cohort, 652 patients). The mean length of stay in the unit for the study cohort was 13.64 days. The most frequent diagnosis was multiple trauma (50.46%). The incidence density of VAP was 20.31 cases per 1000 patient-days on mechanical ventilation. The pathogens most often isolated in early-onset VAP cases were Staphylococcus aureus and Pseudomonas aeruginosa. In late-onset cases, the pathogens were Pseudomonas species. Early-onset VAP was 2.54 and 2.81 times more frequent in comatose and head-injury patients, respectively. Those rates were significantly different in late-onset cases. CONCLUSIONS: Early-onset VAP was more common in comatose and head-injury patients. The risk of developing late-onset versus early-onset VAP was twice as great for postoperative patients.

[PiCCO monitoring of 4 critically ill patients]. / Utilización del monitor PiCCO en cuatro pacientes en estado crítico.

The PiCCO physiological monitor (Pulsion Medical Systems, Munich, Germany) was used for hemodynamic diagnosis and monitoring of 4 patients: a polytraumatized female patient with septic shock and ventilator-associated pneumonia; a man with congestive heart failure and cor pulmonale who developed acute heart failure while recovering from anterior resection of the rectum; a man with severe head injury and acute respiratory distress syndrome; and a polytraumatized male patient with a myocardial contusion. All were in a life-threatening situation, either immediately as in the case of the patient with myocardial contusion or eventually as in the patient with septic shock. The PiCCO monitor recorded hemodynamic parameters satisfactorily, facilitating adjustments to optimize treatment. The risks and complications of the usual method of monitoring by Swan-Ganz catheter are well-known. New less invasive monitoring systems designed to record parameters similar to those detected by the Swan-Ganz catheter but with fewer complications and risks have become available. One example, the PiCCO monitor, combines arterial thermodilution with analysis of the pulse waveform, providing a series of hemodynamic parameters useful for managing the critically ill patient.

[Open cholecystectomy under thoracic epidural anesthesia in diffuse interstitial lung disease]. / Colecistectomía abierta bajo anestesia epidural torácica en enfermedades intersticiales difusas del pulmón.

Two patients, aged 73 and 58 years, with diffuse pulmonary fibrosis underwent emergency open cholecystectomies (subcostal approach) under thoracic epidural anesthesia with 0.5% ropivacaine and fentanyl in spontaneous ventilation. Pulmonary fibrosis was due to amiodarone administration in the first patient and of unknowon cause in the second. Both developed arterial hypotension without bradycardia in spite of optimal preloading. Inotropoic support with low doses of norepinephrine was requiered for recovery in both cases with no adverse events after reversion of the sympathetic blocks. Postoperative epidural analgesia was very satisfactory. Thoracic epidural anesthesia is a useful alternative to general anesthesia for subcostal cholecystectomy in patients with diffuse interstitial lung disease in advanced stages.

[Resuscitation damage control in the patient with severe trauma]. / Reanimación de control de daños en el paciente adultocon trauma grave.

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.

Glomerular hyperfiltration and albuminuria in critically ill patients.

Glomerular hyperfiltration and albuminuria are two pathological conditions that could alter renal drug elimination, but they have been rarely studied in a critical care setting. The aims of this descriptive, prospective study performed on 89 critically ill patients are to determine rates of glomerular hyperfiltration (main objective) and albuminuria (secondary objective). On admission, 17.9% of patients presented with glomerular hyperfiltration, climbing to rates as high as 30% during the first week of admission. Seventy-five percent showed albuminuria on admission, with rates remaining high throughout the week of the study. Since glomerular hyperfiltration as well as albuminuria are frequent pathophysiological conditions in critical care patients, the implications that these phenomena may have regarding drug elimination need further evaluation.