Infused cardioplegia index: A new tool to improve myocardial protection. A cohort study. / Índice de cardioplejía infundida: una nueva herramienta en la protección miocárdica. Un estudio de cohortes.

BACKGROUND: Strategies for cardio-protection are essential in coronary artery bypass graft surgery. The authors explored the relationship between cardioplegia volume, left ventricular mass index and ischemia time by means of the infused cardioplegia index and its relationship with post-operative low cardiac output syndrome. DESIGN: All patients undergoing coronary artery bypass graft surgery between January 2013 and December 2015 were included. Low cardiac output syndrome was defined according to criteria of the SEMICYUC's consensus document. The perioperative factors associated with low cardiac output syndrome were estimated, and using a ROC curve, the optimum cut-off point for the infused cardioplegia index to predict the absence of low cardiac output syndrome was calculated. RESULTS: Of 360 patients included, 116 (32%) developed low cardiac output syndrome. The independent risk predictors were: New York Heart Association Functional Classification (OR 1.8 [95% CI=1.18-2.55]), left ventricle ejection fraction (OR 0.95 (95% CI=0.93-0.98]), ICI (OR 0.99 [95% CI=0.991-0.996]) and retrograde cardioplegia (OR 1.2 [95% CI=1.03-1.50]). The infused cardioplegia index showed an area under the ROC curve of 0.77 (0.70-0.83; P<.001) for the absence of postoperative low cardiac output syndrome using the optimum cut-off point of 23.6ml·min-1(100g/m2 of LV)-1. CONCLUSIONS: The infused cardioplegia index presents an inverse relationship with the development of post-operative low cardiac output syndrome. This index could form part of new strategies aimed at optimising cardio-protection. The total volume of intermittent cardioplegia, especially that of maintenance, should probably be individualised, adjusting for ischemia time and left ventricle mass index.

[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.

[Hydropneumothorax secondary to enteral feeding tube]. / Hidroneumotórax secundario a sonda de nutrición enteral.

The placement of naso-gastric tubes is a routing procedure in Intensive Care Units. Their basic indications are the aspiration of gastric contents, as well as the enteral nutrition of the patients. Despite this being a simple technique, it is not exempt of complications, some of which are very serious, which should be kept in mind in order to prevent them and to diagnose them early. We describe a case of hydro-pneumothorax, secondary to the placement of a naso-gastric tube for enteral nutrition.

[Massive hemoptysis as the onset of pancreatico-bronchial fistula]. / Hemoptisis masiva como presentación de fístula pancreático-bronquial.

OBJECTIVE: A fistula between the pancreas and the bronchial tree is a rare manifestation of pancreatic disease. PATIENTS: We describe a case of a pancreatic pseudocyst that penetrated into the thoracic cavity through the diaphragm, and set up a communication with the bronchial tree developing an episode of massive haemoptysis.

[Generalized convulsive status epilepticus: analysis apropos of 57 cases]. / Status epiléptico convulsivo generalizado: análisis a propósito de 57 casos.

BACKGROUND: The generalized convulsive status epilepticus (GCSE) is a medical emergency with a high morbimortality rate. We analyzed the casuistry in our hospital and we assessed the causes related to mortality. PATIENTS AND METHODS: This is a retrospective study of 57 cases of GCSE that took place between january 1992 to december 1998. The variables studied were mortality among groups according to age, previous epilepsy and the duration of the convulsive episode. RESULTS: We found male prevalence (63.2%). The 49.2% of patients didn't have previous history of epilepsy. In 38.6% of cases the treatment dose was insufficient and in 61.4% it was delated. The mortality rate was 36.8% with a higher significance in patients older than 65 (p < 0.02), without previous history of epilepsy (p < 0.001) and in episodes lasting more than 4 hours (p < 0.05). Only 12.9% of patients received prehospital treatment. CONCLUSIONS: The mortality of GCSE is very high. The initial treatment is inadequate. We must establish a premature and adequate protocol, with optim pharmacological doses and a good coordination with intensive care units.

[Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome]. / Ventilación pulmonar independiente sincronizada en el tratamiento del síndrome de distrés respiratorio del adulto.

INTRODUCTION: Synchronized independent lung ventilation (SILV) is an effective mode of mechanical ventilation for treating both unilateral and bilateral pulmonary lesions. Oxygenation improves with an increase in the ventilation/perfusion ratio and also diminishes the risk of barotrauma. We describe our broad experience with this technique. Our main objective was to confirm whether SILV is able to improve the alveolar-arterial oxygen difference [P(A-a)O2] of patients with severe adult respiratory distress syndrome (ARDS) in whom conventional mechanical ventilation has not brought about improvement after being used for over 48 hours. PATIENTS AND METHODS: We carried out a descriptive, open, controlled prospective study of 45 patients with severe ARDS, enrolled from among 68 who underwent treatment with SILV. The most frequent cause of ARDS in our study was multiple trauma. The patients diagnosed of ARDS who did not improve with conventional mechanical ventilation were treated with SILV. Clinical characteristics and mortality are described. APACHE II scores, PAOA-aO2, dynamic distensibility were analyzed before and after SILV. The results of SILV were considered good if PA-aO2 improved at least 30% within 48 hours, with no increase in distensibility. RESULTS: No complications due to the technique were observed. Twenty-two patients (48.8%) died, 18 as a result of multiple organ failure and only one (4.5%) because of hypoxia. The improvements in APACHE II and (PA-aO2 were statistically significant, while distensibility did not change. The result was defined as good in most cases (n = 34, 83.8%). CONCLUSIONS: SILV is useful for providing ventilatory support when ARDS fails to improve with conventional mechanical ventilation. Clear improvement in respiratory function was observed, with significant decrease in PA-aO2 and no change in distensibility. SILV is a safe technique with few complications and can be managed by the intensive care unit nursing staff.

[Comparative study of percutaneous tracheotomy and conventional surgical tracheotomy in patients with prolonged intubation]. / Estudio comparativo entre la traqueotomía percutánea y la traqueotomía convencional quirúrgica en pacientes con intubación prolongada.

BACKGROUND: Percutaneous tracheotomy (PT) has become an alternative to conventional surgical tracheotomy (CST) in recent years. Our aim was to compare the advantages and disadvantages of the two techniques in our intensive care unit (ICU). PATIENTS AND METHODS: Two patient groups were compared. Sixty underwent PT and 47 underwent CST, and all were admitted to the ICU between May 1995 and August 1997. PT was performed in 49 by way of progressive dilations, and 11 were performed by Griggs' method using a dilator. Variables studied were age, sex, reason for admission, APACHE II upon admission to the ICU, duration of technique, and immediate and late complications. Statistical analysis was provided by applying a Student t test to contrast quantitative variables and a chi-squared test to compare proportions. RESULTS: The following variables were significantly different. APACHE II upon admission was 18 +/- 5 in the PT group and 15 +/- 6 in the CST group (p < 0.002). Duration of the procedure was 15 +/- 4 minutes in the PT group and 36 +/- 11 in the CST group (p < 0.005). Complications after tracheotomy in PT group patients consisted of 1 false line during a change of cannula and 1 late tracheoesophageal fistula. Complications in the CST group included 16 episodes of slight bleeding, 9 stoma infections, 3 cases of pneumothorax, 2 of bad scarring of the stoma and 1 late fistula (p < 0.005). Time of follow-up was 41 to 76 days for PT patients and 32 to 51 days for CST patients. CONCLUSIONS: PT is a fast, simple procedure that is easy to manage and requires fewer resources (operating theater, personnel and equipment) and causes fewer medium-term complications than does CST.

[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.