Evidence-based guides in tracheostomy use in critical patients. / Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico.

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients.

INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. METHODOLOGY: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. CONCLUSIONS: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.

[Complications in posterior ankle arthroscopy by classic and non-distraction portals]. / Complicaciones en la artroscopía posterior de tobillo por portales clásicos y sin distracción.

INTRODUCTION: Posterior ankle arthroscopy allows the diagnosis and treatment of multiple pathologies through minimal trauma. The use of posterior portals associated or not to mechanical distraction, allows a good vision of the posterior ankle, tendons of the region, and subtalar joint. OBJECTIVES: We evaluated intra- and postoperative complications of posterior ankle arthroscopy without joint distraction, and compared them with those described in international literature. MATERIAL AND METHODS: A retrospective study that evaluated 49 patients undergoing posterior ankle arthroscopy for several pathologies. All of them operated by a single surgeon, in two health institutions, for seven years. RESULTS: were analyzed using the visual analog scale and the AOFAS score. Intra- and postoperative complications were recorded. The average follow-up was 28 months. RESULTS: 33 men and 16 women. The average age was 38.6 years old. There were seven complications (14.3%): paresthesia and - or hypoesthesia of the sural nerve (four cases), residual pain in the portal (two cases), and portal scar dehiscence (one patient). The average improvement of VAS was 5.53 points, and the improved AOFAS score was an average of 35.78 points. CONCLUSIONS: Posterior ankle arthroscopy without distraction through the classic postero-lateral and posteromedial portals is a safe technique, with a low rate of complications.

INTRODUCCIÓN: La artroscopía posterior de tobillo permite el diagnóstico y tratamiento de múltiples patologías a través de un mínimo trauma. Los portales posteriores, asociados o no a distracción mecánica, permiten una buena visión de los tendones de la región y articulación substragalina. OBJETIVO: del presente estudio es evaluar las complicaciones intraoperatorias y postoperatorias de la artroscopía posterior del tobillo y retropié sin distracción articular y compararlas con las descritas en la bibliografía internacional. MATERIAL Y MÉTODOS: Estudio retrospectivo que evaluó 49 pacientes sometidos a artroscopía posterior de tobillo por diversas patologías. Todos operados por un único cirujano, en dos instituciones de salud, durante un período de siete años. Se analizaron los resultados mediante la escala visual analógica (EVA) y la escala de la American Orthopaedic Foot and Ankle Society (AOFAS, por sus siglas en inglés). Se consignaron las complicaciones intra- y postoperatorias. El seguimiento promedio fue de 28 meses. RESULTADOS: 33 varones y 16 mujeres (edad promedio 38.6 años). Hubo siete complicaciones (14.3%): cuatro parestesias y/o hipoestesia del nervio sural, dos casos de dolor residual en un portal y un caso de dehiscencia de cicatriz. Mejoría promedio de EVA de 5.53 puntos y mejoría promedio del AOFAS de 35.78 puntos. CONCLUSIONES: La artroscopía posterior de tobillo sin distracción por medio de los clásicos portales posterolateral y posteromedial es una técnica segura, con un bajo índice de complicaciones mayores y una baja morbilidad para el paciente.

Fate of rejected manuscripts in the journal Medicina Intensiva during 2015-2017 period. / Destino de los artículos rechazados en Medicina Intensiva en el período 2015-2017.

OBJECTIVE: To know the fate of the rejected manuscripts in Medicina Intensiva journal (MI) from 2015 to 2017 with surveillance until 2019. DESIGN: Retrospective observational study. SETTING: Biomedical journals publication. PARTICIPANTS: Rejected manuscripts in MI journal. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Time of publication, impact factor (IF), generated citations and variables associated to publication. RESULTS: The 69% (420) of analyzed articles (344 originals and 263 scientific letters) were rejected, and 205 (48.8%) were subsequently published, with 180 citations of 66 articles. Journal IF was lower in 173 (84.4%) articles. The number of FI-valid citations was higher than the FI of MI in 21 articles. Origin of manuscript OR 2,11 (IC 95% 1.29 - 3.46), female author OR 1.58 (IC 95% 1.03-2.44), english language OR 2,38 (IC 95% 1.41-4.0) and reviewed papers OR 1.71 (IC 95% 1.10-2.66) were associated to publication in PubMed database. CONCLUSIONS: The rejected articles in MI have a mean publication rate in other journals. Most of these articles are published in journals with less IF and fewer citations than the IF of MI.

Fate of rejected manuscripts in the journal Medicina Intensiva during 2015-2017 period.

OBJECTIVE: To know the fate of the rejected manuscripts in Medicina Intensiva journal (MI) from 2015 to 2017 with surveillance until 2019. DESIGN: Retrospective observational study. SETTING: Biomedical journals publication. PARTICIPANTS: Rejected manuscripts in MI journal. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Time of publication, impact factor (IF), generated citations and variables associated to publication. RESULTS: The 69% (420) of analyzed articles (344 originals and 263 scientific letters) were rejected, and 205 (48.8%) were subsequently published, with 180 citations of 66 articles. Journal IF was lower in 173 (84.4%) articles. The number of FI-valid citations was higher than the FI of MI in 21 articles. Origin of manuscript OR 2,11 (IC 95% 1.29-3.46), female author OR 1.58 (IC 95% 1.03-2.44), english language OR 2,38 (IC 95% 1.41-4.0) and reviewed papers OR 1.71 (IC 95% 1.10-2.66) were associated to publication in PubMed database. CONCLUSIONS: The rejected articles in MI have a mean publication rate in other journals. Most of these articles are published in journals with less IF and fewer citations than the IF of MI.

[Recurrent dislocation of peroneal tendons. Minimally invasive technique for the deepening of the groove]. / Luxación recidivante de tendones peroneos. Técnica mínimamente invasiva para la profundización del surco.

INTRODUCTION: Since William Clancy (1979) and Richard Ferkel (1997) publications, the technique of peroneal groove deepening in patients with chronic dislocation, has been used with very satisfactory results and few complications. The aim of the present study is to describe a new minimally invasive technique of peroneal groove deepening with burs and specific percutaneous surgery instrumentation and without fibula osteotomy; and to evaluate the clinical and imaging results, in 5 patients operated with this technique. MATERIAL AND METHODS: A retrospective study of 5 patients with clinical and imaging diagnosis of chronic dislocation of peroneal tendons. They were treated with minimally invasive technique. This technique was described in this paper. Results were evaluated by preoperative and postoperative AOFAS score and by images (dynamic ultrasound, TAC and RMN). RESULTS: None of the treated patients presented dislocation recurrence or pain at the time of evaluation. The AOFAS score improved an average of 25.5 points and was statistically significant (p value 0.001). In the images we observed a concavity of the groove in all the evaluated cases. CONCLUSIONS: This minimally invasive technique of deepening the groove of the peroneal tendons is reproducible, has reduced operating times compared to open surgery and has excellent results. This is a noninvasive treatment alternative for dislocation of peroneal tendons.

INTRODUCCIÓN: Desde las publicaciones de William Clancy en 1979 y las de Richard Ferkel en 1997, la técnica de profundización del surco en pacientes con luxación crónica de los peroneos ha sido ampliamente utilizada, obteniendo resultados muy satisfactorios y escasas complicaciones. El objetivo del presente trabajo es describir una nueva técnica de profundización del surco mínimamente invasiva con fresas y un motor específico de cirugía percutánea, sin osteotomía y sin dejar lecho cruento del peroné, además de evaluar los resultados clínicos e imagenológicos en cinco pacientes operados con esta técnica. MATERIAL Y MÉTODOS: Se realizó un estudio retrospectivo de cinco pacientes con diagnóstico clínico y de imágenes de luxación crónica de tendones peroneos intervenidos con técnica mínimamente invasiva, la cual ya fue descrita. Los resultados fueron evaluados mediante el score AOFAS (por sus siglas en inglés American Orthopedic Foot and Ankle Score) de manera pre y postquirúrgica y a través de imágenes (ecografía dinámica, tomografía axial computada y resonancia magnética nuclear). RESULTADOS: Ninguno de los pacientes tratados presentó recidiva de luxación ni dolor al momento de la evaluación. El score AOFAS mejoró en promedio 25.5 puntos y fue estadísticamente significativo (p 0.001). En las imágenes observamos una concavidad del surco en todos los casos evaluados. CONCLUSIONES: Creemos que esta técnica mínimamente invasiva de profundización del surco de los peroneos es reproducible y presenta tiempos operatorios reducidos, comparada con la cirugía a cielo abierto; además tiene excelentes resultados. Por tales motivos, consideramos que se trata de una alternativa de tratamiento poco invasiva para la luxación de los tendones peroneos.

[Contingency plan for the intensive care services for the COVID-19 pandemic]. / Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19.

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

Contingency Plan for the Intensive Care Services for the COVID-19 pandemic. / Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19.

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC, have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

Evidence-based clinical practice guidelines for the management of sedoanalgesia and delirium in critically ill adult patients. / Guías de práctica clínica basadas en la evidencia para el manejo de la sedoanalgesia y delirium en el paciente adulto críticamente enfermo.

Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented.

The Pan American and Iberian Federation of Critical Medicine and Intensive Therapy develops its Strategic Plan. / La Federación Panamericana e Ibérica de Medicina Crítica y Terapia Intensiva elabora su plan estratégico.

The Pan-American and Iberian Federation of Critical Medicine and Intensive Therapy, A.C. (FEPIMCTI), has prepared its Strategic Plan for the next 5 years. In this Plan, it defines its course towards the future, establishes its long-term objectives and works to achieve success. Its strategic objectives are framed in consolidating the legal, fiscal and administrative structure, the updating of its statutes, the implementation of a process management system encompassed in a quality culture, the implementation of committees of experts, achieving academic excellence by developing training programs and giving visibility to the Federation. Their main values refer to equity, professionalism, respect and social solidarity. The implementation of the Strategic Plan in a collaborative manner must serve as a driving force for change to position FEPIMCTI as a relevant Scientific Society in the Critical Medicine of its member countries.

Luxación recidivante de tendones peroneos. Técnica mínimamente invasiva para la profundización del surco / Recurrent dislocation of peroneal tendons. Minimally invasive technique for the deepening of the groove

Resumen: Introducción: Desde las publicaciones de William Clancy en 1979 y las de Richard Ferkel en 1997, la técnica de profundización del surco en pacientes con luxación crónica de los peroneos ha sido ampliamente utilizada, obteniendo resultados muy satisfactorios y escasas complicaciones. El objetivo del presente trabajo es describir una nueva técnica de profundización del surco mínimamente invasiva con fresas y un motor específico de cirugía percutánea, sin osteotomía y sin dejar lecho cruento del peroné, además de evaluar los resultados clínicos e imagenológicos en cinco pacientes operados con esta técnica. Material y métodos: Se realizó un estudio retrospectivo de cinco pacientes con diagnóstico clínico y de imágenes de luxación crónica de tendones peroneos intervenidos con técnica mínimamente invasiva, la cual ya fue descrita. Los resultados fueron evaluados mediante el score AOFAS (por sus siglas en inglés American Orthopedic Foot and Ankle Score) de manera pre y postquirúrgica y a través de imágenes (ecografía dinámica, tomografía axial computada y resonancia magnética nuclear). Resultados: Ninguno de los pacientes tratados presentó recidiva de luxación ni dolor al momento de la evaluación. El score AOFAS mejoró en promedio 25.5 puntos y fue estadísticamente significativo (p < 0.001). En las imágenes observamos una concavidad del surco en todos los casos evaluados. Conclusiones: Creemos que esta técnica mínimamente invasiva de profundización del surco de los peroneos es reproducible y presenta tiempos operatorios reducidos, comparada con la cirugía a cielo abierto; además tiene excelentes resultados. Por tales motivos, consideramos que se trata de una alternativa de tratamiento poco invasiva para la luxación de los tendones peroneos.

Abstract: Introduction: Since William Clancy (1979) and Richard Ferkel (1997) publications, the technique of peroneal groove deepening in patients with chronic dislocation, has been used with very satisfactory results and few complications. The aim of the present study is to describe a new minimally invasive technique of peroneal groove deepening with burs and specific percutaneous surgery instrumentation and without fibula osteotomy; and to evaluate the clinical and imaging results, in 5 patients operated with this technique. Material and methods: A retrospective study of 5 patients with clinical and imaging diagnosis of chronic dislocation of peroneal tendons. They were treated with minimally invasive technique. This technique was described in this paper. Results were evaluated by preoperative and postoperative AOFAS score and by images (dynamic ultrasound, TAC and RMN). Results: None of the treated patients presented dislocation recurrence or pain at the time of evaluation. The AOFAS score improved an average of 25.5 points and was statistically significant (p value< 0.001). In the images we observed a concavity of the groove in all the evaluated cases. Conclusions: This minimally invasive technique of deepening the groove of the peroneal tendons is reproducible, has reduced operating times compared to open surgery and has excellent results. This is a noninvasive treatment alternative for dislocation of peroneal tendons.

Assessment of neutron dosemeters around standard sources and nuclear fissile objects.

In order to evaluate the neutron doses around nuclear fissile objects, a comparative study has been made on several neutron dosemeters: bubble dosemeters, etched-track detectors (CR-39) and 3He-filled proportional counters used as dose-rate meters. The measurements were made on the ambient and the personal dose equivalents H*(10) and Hp(10). Results showed that several bubble dosemeters should have been used due to a low reproducibility in the measurements. A strong correlation with the neutron energy was also found, with about a 30% underestimation of Hp(10) for neutrons from the PuBe source, and about a 9% overestimation for neutrons from the 252Cf source. Measurements of the nuclear fissile objects were made using the CR-39 and the dose-rate meters. The CR-39 led to an underestimation of 30% with respect to the neutron dose-rate meter measurements. In addition, the MCNP calculation code was used in the different configurations.

Evidence-based guides in tracheostomy use in critical patients

Objetivos: Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios. Métodos: Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network(LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B = 3, 2C = 3, 2D = 4) y 9 negativas (1B = 8, 2C = 1). En 6 ocasiones no se pudieron establecer recomendaciones. Conclusión: La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones.(AU)

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.(AU)

[Latin American survey on delirium in critical patients]. / Encuesta iberoamericana sobre delirium en pacientes críticos.

OBJECTIVES: This study has aimed to establish the intensivist physician's concepts and practices in this region regarding the diagnosis, management and prevention of delirium in intensive care units (ICU). DESIGN: A survey was distributed among the FEPIMCTI member societies for distribution among its medical members. RESULTS: Eight hundred fifty-four intensive care physicians from 12 Latin America countries, most of them from Argentina, Mexico, Chile and Colombia, responded to the survey. There was a majority of academic ICUs (70.5%). A total of 56.55% responded that they always evaluated the diagnosis of delirium and only 10.2% answered never. A general clinical assessment was made by 69.5%, only 19.6% used the CAM-ICU scale and 9% the checklist assessment of delirium. It was agreed or strongly agreed by 88.3% that delirium was an expected event in the ICU and by 90.1% that delirium was underdiagnosed in ICU. A total of 97% responded that it was a problem that requires intervention and which is preventable (66.5%). It was considered that excessive sedation is given in the ICU by 74.5% and 70.5% believed that opiates are associated with the onset of delirium, while 87.1% considered that some sedatives are associated with its development. Ventilator-associated pneumonia (VAP) was considered as a risk factor by 70.2% of the respondents and 87.8% considered that it made extubation difficult. CONCLUSIONS: Although delirium is considered to be a common and preventable problem with serious implications for critically ill patients, the intensivist physicians surveyed do not use a tool for its evaluation in the ICU. Educational efforts are needed to disseminate the effectiveness and usefulness of the scales that allow for early and accurate diagnosis of delirium in the ICU.

Organización más allá de los algoritmos en la vía aérea dificultosa. "PENSAR globalmente y ACTUAR localmente" / Organization beyond the algorithms in the airway difficult. "THINK globally and ACT locally "

Objetivo: Evaluar el impacto sobre la tasa de complicaciones en la intubación orotraqueal con la implementación de un protocolo de actuación en el manejo de la vía aérea. Materiales y Métodos: Pacientes admitidos al Servicio de Terapia Intensiva polivalente entre agosto de 2012 y marzo de 2014, que requirieron intubación orotraqueal. Se utilizó un protocolo de actuación "Pensar globalmente y Actuar localmente" durante el proceso de preintubación, intubación y posintubación, que incluye valoración de las vías aéreas, planes de seguridad, optimización cardiovascular y pulmonar. Las complicaciones fueron: 1) intubación dificultosa, 2) intubación esofágica, 3) traumatismo de la vía aérea superior, 4) broncoaspiración, 5) arritmias cardíacas, 6) paro cardiocirculatorio. Se compararon las tasas de complicaciones durante dos períodos: Período 1 (P1): de agosto de 2010 a julio de 2012, en el que se realizó la intubación orotraqueal mediante la Secuencia de Intubación Rápida, y Período 2 (P2): de agosto de 2012 a marzo de 2014, en el que se implementó el protocolo "Pensar globalmente y Actuar localmente". Se evaluaron características demográficas, puntajes APACHE II y SOFA, complicaciones de la intubación, estancia en Terapia Intensiva y mortalidad. El análisis estadístico se realizó utilizando la media, la desviación estándar y la prueba de Fisher para las variables cuantitativas y la prueba de χ2 para las variables dicotó- micas. Se consideró significativa una probabilidad de error <5% (p <0,05). Resultados: 374 pacientes requirieron intubación orotraqueal: 180 (48,1%) en el P1 y 194 (51,8%) en el P2; edad: 59 ± 18 años (P1) y 61 ± 18 años (P2); APACHE II: 18 (P1) y 16 (P2); SOFA: 8 ± 2 y 7 ± 3, respectivamente; complicaciones: P1, 24 (13%), P2, 7 (3,6%) (p <0,001); intubación dificultosa: P1, 8 (33,3%), P2, 1 (14,2%) (p <0,005); intubación esofágica: P1, 3 (12,5%), P2, 1 (14,2%); traumatismo de la vía aérea superior: P1, 5 (21,3%), P2, 2 (28,5%); broncoaspiración: P1, 4 (16,6%), P2, 1 (14,2%); arritmias: P1, 3 (12,5%), P2,2 (28,5%), paro cardiocirculatorio: P1, 1 (4,1%), P2: 0. Estancia en Terapia Intensiva: 13.5 ± 3 días (P1) y 12.8 ± 1.2 días (P2). Mortalidad 10% (P1) y 6,2% (P2) (NS). Conclusión: La aplicación de un protocolo para el manejo de la vía aérea redujo, con significación estadística, la tasa de complicaciones, en particular, la intubación dificultosa. (AR)

Objective: To evaluate the impact of a protocol for the management of the airway on the complication rate in tracheal intubation. Materials and Methods: Patients requiring orotracheal intubation admitted to the Intensive Care Unit from August 2012 to March 2014 were included. The "Think globally and Act locally" protocol was used during pre-intubation, intubation and after intubation, including assessment of the airway, safety plans, cardiovascular and pulmonary optimization. Complications: 1) difficult intubation, 2) esophageal intubation, 3) upper airway trauma, 4) aspiration, 5) arrhythmias, 6) cardiac arrest. Rates of complications were compared during two periods: Period 1 (P1): from August 2010 to July 2012 where orotracheal intubation was conducted through rapid sequence intubation, and Period 2 (P2) from August 2012 to March 2014, where "Think globally and Act locally" protocol was implemented. Demographic characteristics, APACHE II and SOFA scores, complications of intubation, length of stay in the Intensive Care Unit, and mortality were evaluated. Statistical analyses were performed using mean, standard deviation, and Fisher test for quantitative variables and chi square test for dichotomous variables; a probability of error <5% (p <0,05) was considered significant. Results: 374 patients required tracheal intubation: 180 (48.1%) during P1 and 194 (51.8%) during P2; mean age: 59 ± 18 years (P1) and 61 ± 18 years (P2); APACHE II score: 18 (P1) and 16 (P2); SOFA score: 8 ± 2 (P1) and 7 ± 3 (P2); complications: P1, 24 (13%); P2, 7 (3.6%) (p <0.001); difficult intubation: P1, 8 (33.3%), P2, 1 (14.2%) (p <0.005); esophageal intubation: P1, 3 (12.5%), P2, 1 (14.2%), upper airway trauma: P1, 5 (21.3%), P2, 2 (28.5%); aspiration: P1, 4 (16.6%), P2, 1 (14.2%); arrhythmias: P1, 3 (12.5%), P2, 2 (28.5%); cardiac arrest: P1, 1 (4.1%), P2, 0; stay in the Intensive Care Unit: 13.5 ± 3 (P1) and 12.8 ± 1.2 days (P2); mortality: 10% (P1) and 6.2% (P2) (NS). Conclusion: Implementation of a protocol for the management of the airway decreased complications with statistical significance, including difficult intubation.(AR)

Inmunoglobulina (ig) polivalente en el tratamiento de la sepsis abdominal / Polyvalent immunoglobulin (Ig) in the treatment of intraabdominal sepsis

La sepsis grave mantiene una elevada mortalidad en los últimos 40 años. Múltiples intentos por moderar la respuesta inflamatoria sistémica, mediante la infusión de inmunoglobulinas (Ig), han demostrado resultados controvertidos. Los diferentes criterios de diagnóstico, la diferente población en estudio y reducido número de pacientes, dificultan obtener conclusiones definitivas. Objetivo: Evaluar si la infusión de Ig mejora la evolución de pacientes con sepsis abdominal. Lugar: 7 unidades de Cuidados Intensivos Polivalentes. Diseño: Estudio multicéntrico, prospectivo, randomizado, doble ciego. Intervenciones: Los pacientes fueron asignados aleatoriamente para recibir Ig (Grupo A: GA) o placebo (Grupo B: GB) conjuntamente con el tratamiento habitual de la sepsis abdominal. Resultado: Treinta y siete pacientes fueron incluidos en el estudio. 20 en el GA y 17 en el GB. El nivel medio de APACHE II, TISS, las disfunciones y fallas orgánicas no fueron diferentes entre los grupos. La mortalidad general fue del 16,7 por ciento, superior en el GB (26 por ciento) respecto del GA (5 por ciento) aunque tal diferencia no alcanzó significación estadística. Conclusiones: Nuestros hallazgos sugieren, que la infusión de Ig (Pentaglobin) en pacientes con sepsis abdominal con foco resuelto, reduce la mortalidad al alta de la UCI. Nuevos estudios clínicos son necesarios para confirmar los presentes hallazgos

Predictores de mortalidad en el traumatismo cerrado de tórax / Predictive factors of mortality in blunt chest trauma

Objetivo: Valorar los predictores de mortalidad en politraumatizados con traumatismo cerrado de tórax en un área crítica. Material y métodos: Estudio de cohorte no concurrente evaluando los datos de pacientes politraumatizados con trauma de tórax. Los datos analizados incluyen: edad, sexo, mecanismo del trauma, mortalidad, lesiones torácicas específicas: hemotórax, neumotórax, número de costillas fracturadas < de 4 o = a 4 y contusión pulmonar. Para cada paciente se calcularon: Trauma Score Revisado (TSR), Score de Injuria Abreviada (AIS), Escala de Severidad Lesional (ISS) y variables de intercambio gaseoso (Pa/FiO2' a/A )2). La presencia de traumatismo encefalocraneal (TEC) grave fue valorado con un Score de Coma de Glasgow (GCS) = a 8. El procedimiento estadístico se realizó utilizando Chi Cuadrado o el Test de Mann Witney según correspondiese. Un valor de p menor a 0,05 fue considerado significativo. Los datos se expresan como valores medios con su correspondiente desvío estandard. Resultados: Se ingresaron 706 pacientes politraumatizados entre enero de 1987 y diciembre de 1996. Ciento cuarenta y dos (20,11 por ciento) presentaron traumatismo cerrado de tórax. 122 (85,91 por ciento) fueron hombres y 20 mujeres, con una edad promedio de 41,96 años. El mecanismo del trauma involucrado fue: ocupantes de vehículo en 55, peatones 39 y por caída de altura 48. La mortalidad global fue 35,91 por ciento. No hubo diferencia estadísticamente significativa en cuanto a edad, sexo y mecanismo de trauma entre muertos y sobrevivientes. Dentro de las lesiones torácicas específicas mostraron significación estadística el mayor número de costillas fracturadas (= a 4) p < 0,0037 y la contusión pulmonar p 0,028, no así la presencia de hemotórax o neumotórax. El ISS fue 43,6 ñ 16,8 y el AIS Tórax fue 3,6 ñ 1,1 para los que fallecieron y 27,4 ñ 12,3 y 3,0 ñ 1,1 para los sobrevivientes p < 0,0001 y p < 0,0004 respectivamente. El valor del TSR fue significativamente menor entre los muertos 9,0 ñ 2,7 que entre los sobrevivientes TRS 11,1 ñ 1,1 p < 0,001. Analizadas las variables de intercambio gaseoso la media aritmética del Pa/FiO2 fue de 248,9 ñ 122,9 entre los fallecidos y de 299,9 ñ 95,0 para los sobrevivientes p < 0,013 y la media del a/A O2 fue de 0,43 ñ 0,23 y 0,54 ñ 0,18 para cada grupo, p < 0,004. La presencia de TEC grave asociado fue indicador pronóstico de mortalidad p < 0,000003...