Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology. / Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR).

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report. / Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso.

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.

[Unilateral pleural effusion caused by vessel perforation due to peripherally inserted central catheter: Indocyanine green as a diagnostic tool]. / Derrame pleural unilateral tras perforación vascular por catéter venoso central de inserción periférica: utilidad del verde de indocianina en el diagnóstico.

A peripherally inserted central catheter (PICC) was inserted into a 44-year-old man to provide parenteral nutrition in a protein-calorie malnutrition secondary to a benign pyloric stenosis. On the fifth day while monitoring the catheter, the patient presented with a massive whitish pleural effusion after undergoing gastric endoscopy in order to treat pyloric stenosis. Chylothorax was initially suspected, and the patient was admitted to a recovery unit. Indocyanine green was administered through the PICC, obtaining a greenish discoloration in the pleural effusion 30 min later. This led to the diagnosis of a pleural effusion caused by a vessel perforation due to the PICC, leading to parenteral nutrition extravasation. Thoraco-abdominal computed tomography was performed, which confirmed an innominate vein perforation due to the PICC. PICC insertion may be associated with severe complications, such as central vessel perforation, and therefore the correct position of a central catheter should be always checked. Intravenous computed tomography contrast is the gold standard for central vascular perforation diagnosis. However if a pleural effusion occurs in this context, it is possible to use a dye, which administered intravenously can lead us to the correct diagnosis in situ. Indocyanine green was used for this purpose in this case.

Left anterior hemiblock, complete right bundle branch block and sinus tachycardia in maprotiline poisoning.

Maprotiline is a tetracyclic drug with effects similar to those of tricyclic antidepressants. It has been suggested that tetracyclic antidepressants have fewer cardiovascular side-effects. We describe a case with serious alteration of intraventricular conduction after maprotiline overdosage.

Pourfour du Petit syndrome: a case following a traffic accident with severe cranioencephalic trauma.

Poufour du Petit syndrome is an extraordinarily unusual clinical condition produced by hyperactivity of the sympathetic cervical chain as a consequence of irritation of these nerves. It causes an ipsilateral mydriasis, which, in patients suffering a head injury as in the case reported here, can confuse the diagnosis and disconcert physicians.

[Early postoperative medical complications of orthotopic liver transplantation in adults (I)]. / Complicaciones médicas postoperatorias precoces del trasplante hepático ortotópico en adultos (I).

The outcome of liver transplantation in Spain has improved since our earliest experiences with this type of surgery, mainly due to breakthroughs in surgical and anesthetic techniques. Careful postoperative care of the patient also plays a key role, however, by providing the early diagnosis that allows appropriate management of complications. Together, such improvements contribute to reducing the morbidity associated with liver transplantation and to greater survival and quality of life for recipients. Early postoperative complications are diverse in nature and for convenience can be classified as either medical or surgical. This review deals with the main medical complications.

[Craniocerebral injuries: initial treatment and at resuscitation units]. / Traumatismo craneoencefálico: tratamiento inicial y en unidades de reanimación.

Head injury is the main cause of death or disability among under-45-year-olds. This review covers the main pathophysiological aspects of head injury as well as initial treatment and management in the intensive care recovery ward. The chief therapeutic aim is to maintain adequate cerebral perfusion pressure rather than to maintain normal levels of intracranial pressure. An important challenge is to avoid development of secondary lesions, and in this context arterial hypotensive events that affect prognosis and the survival of such patients merit special attention. We reject treatment based on indiscriminate use of hyperventilation and mannitol and underline the importance of providing adequate sedation and analgesia while maintaining normal flow and pressure and adequate monitoring of such patients.

[Early postoperative surgical complications of orthotopic liver transplantation in adults (II)]. / Complicaciones quirúrgicas postoperatorias precoces del trasplante hepático ortotópico en adultos (II).

Early postoperative complications after liver transplantation are classified broadly as either medical or surgical. This review covers the main aspects of the pathophysiology and clinical management of the latter group. Surgical complications of liver transplantation are an important cause of morbimortality; their early diagnosis and treatment are therefore critical issues. Such complications are usually related to surgical technique and their correction often requires a second surgical procedure. The most common early postoperative complication, and one of the most serious ones, is hepatic artery thrombosis. Venous complications are less prevalent and biliary ones predominate in the late postoperative phase.

[Fatal poisoning by the rupture of intestinal bags of cocaine]. / Intoxicación mortal por rotura de bolsas intestinales de cocaína.

We report a case of rupture of bags filled with cocaine into the digestive apparatus in a young man. He carried into his digestive tract one hundred of small bags containing 40 g of cocaine each one. The initial clinical picture was characterized by sympathetic hyperactivity, rectorrhagia, and psychosis that evolved in 72 h to neurologic coma, convulsions, rhabdomyolysis, hyperthermia, hypocalcemia, hyperdynamic picture with negative blood cultures, arterial hypotension, syndrome of adult respiratory distress, and multiorgan failure. Treatment with propranolol, mechanic ventilation, barbiturates and inotropic agents was ineffective and the patient died 7 days after.

[Metamizol versus propacetamol: comparative study of the hemodynamic and antipyretic effects in critically ill patients]. / Metamizol frente a propacetamol: estudio comparativo de los efectos hemodinámicos y antipiréticos en pacientes críticamente enfermos.

OBJECTIVE: To compare the antipyretic and hemodynamic effects of metamizol and propacetamol in critically ill patients with fever. PATIENTS AND METHODS: A prospective randomized trial enrolling 60 patients admitted to our postoperative intensive care unit with fever > 38 degrees C. Patients were assigned to group M to receive intravenous doses of 2 g of metamizol or group P to receive 2 g of propacetamol. Measures were central temperature (Ta), systolic (SBP), diastolic (DBP) and mean (MBP) blood pressures, mean pulmonary artery pressure, central venous pressure, pulmonary capillary pressure, pulmonary and systemic vascular resistance index, and mixed venous saturation. All measures were taken at four times: baseline and 30, 60 and 120 minutes after infusion of the medication. Patients whose SBP fell below 90 mm Hg were withdrawn from the study. RESULTS: Patient characteristics and baseline hemodynamics and Ta were similar in the two groups. We observed a significant decrease in temperature in both groups, the maximum decrease occurring 120 minutes after administration of the antipyretic (0.5 degree C and 0.6 degree in the metamizol and propacetamol groups, respectively). SBP, DBP, MBP, and the vascular resistance index decreased from baseline values in both groups 30, 60 and 120 minutes after dosing. Thirteen percent of the patients in group M and 6.67% in group P were withdrawn from the study because of hypotension. We observed no statistically significant differences between the groups in Ta or hemodynamic variables at any of the four moments of measurement. CONCLUSION: Both metamizol and propacetamol are effective antipyretics at the doses tested. However, both have adverse hemodynamic side effects that may be poorly tolerated by critically patients.

[Improved oxygenation with nitric oxide treatment for hepatopulmonary syndrome after a liver transplant]. / Mejoría de la hipoxemia, en un síndrome hepatopulmonar tras trasplante hepático, mediante la utilización de óxido nítrico inhalado.

A 37-year-old man with cirrhosis of the liver hospitalized for orthotopic liver transplant (OLT) was found to have hepatopulmonary syndrome (HPS) during routine presurgical assessment. No problems with oxygenation developed during surgery. In the early recovery period, however, hypoxemia was observed to be uncorrected in spite of gradual normalization of liver function tests. OLT sometimes corrects HPS and, therefore, hypoxemia. However, significant decreases in oxygenation during recovery have been reported to affect patient morbidity and mortality. We therefore started low-dose nitric oxide (NO) inhalation once other possible causes of hypoxemia had been ruled out. Oxygenation improved, allowing tubes to be removed. Seven months after OLT, home oxygen therapy was still required to treat basal hypoxemia. HPS persisted, as confirmed by echocardiogram. Inhaled NO contributed to maintenance of adequate oxygenation during the early postoperative period, as essential for long-term survival in patients with HPS who undergo OLT.