[Recommendations for the management of emergencies in patients with diabetes, acute metabolic complications of diabetes, and steroid-related hyperglycemia]. / Recomendaciones de manejo de la diabetes, de sus complicaciones metabólicas agudas y de la hiperglucemia relacionada con corticoides en los servicios de urgencias.

EN: Persons with diabetes make up a large percentage of patients attended in the emergency department. Most will be discharged, but patients who remain under observation in wards managed by the emergency department or who wait are waiting to be admitted to a conventional ward must receive appropriate, protocol-guided treatment for their diabetes. Situations of hyper- or hypoglycemia must be avoided because both worsen prognosis. Emergency physicians must correctly and efficiently prevent, diagnose, and manage acute metabolic complications of diabetes such as simple hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. They must also be ready to prescribe and properly administer intravenous insulin to critically ill patients. Hyperglycemia induced by treatment with steroids deserves special mention. If this complication develops, the hyperglycemia is intense, influenced by increased insulin resistance and gluconeogenesis in the liver. Thus, it usually appears after meals and is dependent on steroid dose, duration of treatment, and individual predisposition. The recommendations in this paper elaborated by consensus of the Spanish Society of Emergency Medicine (SEMES) experts, are the first to be written specifically for use in emergency departments in Spain. They give a detailed, in-depth overview of emergencies related to diabetes and diabetic complications.

ES: Un alto porcentaje de los pacientes atendidos en urgencias son diabéticos. La mayoría serán dados de alta. Sin embargo, los que se quedan en observación, ingresados en unidades dependientes de urgencias o los que quedan pendientes de ingreso en hospitalización convencional deben recibir un tratamiento correcto y protocolizado en cuanto a su diabetes, que evite tanto la hiper como la hipoglucemia, ya que ambas son situaciones que empeorarán el pronóstico del paciente. Por otro lado, los urgenciólogos deben prevenir, diagnosticar y manejar de una manera correcta y eficiente las complicaciones metabólicas agudas de la diabetes como son la hiperglucemia simple, la cetoacidosis diabética, la situación hiperosmolar y la hipoglucemia, así como las indicaciones y la forma de administración de insulina intravenosa en los pacientes críticos. Una mención aparte requiere también la hiperglucemia reactiva al tratamiento corticoideo. Esta hiperglucemia, en el caso de aparecer, es intensa y está influenciada por el aumento de la resistencia a la insulina y de la neoglucegénesis hepática que provocan los corticoides, por lo que será de predominio postprandial. Depende de la dosis y duración del tratamiento corticoideo además de una predisposición individual. Las recomendaciones que aquí se exponen, procedentes del consenso alcanzado por el grupo de expertos de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), son las primeras redactadas en España dirigidas exclusivamente a los servicios de urgencias y que hacen una revisión pormenorizada y profunda sobre todas las situaciones que pueden encontrarse en cuanto a la diabetes y sus complicaciones.

[Bacterial meningitis due to gram-negative bacilli in adults]. / Meningitis bacteriana por bacilos gramnegativos en adultos.

INTRODUCTION: Gram-negative bacilli are causative agents of bacterial meningitis in the neonatal period but rarely cause meningitis in adults without risk factors. AIM: To report on meningitis due to gram-negative bacilli (MGNB) in adults diagnosed in a hospital over a 25-year period. PATIENTS AND METHODS: We reviewed the medical records of all patients with an age > or = 14 years who had been diagnosed with MGNB between 1982 and 2006. RESULTS: Fifteen cases of MGNB are included (10.5% of the cases of bacterial meningitis with an identified aetiology), with a mean age of 48 years (14-79). Twelve (80%) were post-operative: recent neurosurgery (9 cases, 75%) and having a neurosurgical device (8 cases, 67%) were risk factors. Three (20%) were spontaneous: two were of a urinary origin and one had an undetermined origin. The aetiology was: Pseudomonas aeruginosa (3 cases), Escherichia coli (3 cases), Enterobacter aerogenes (2 cases), Pseudomonas fluorescens (1 case), Klebsiella pneumoniae (1 case), Morganella morganii (1 case), Acinetobacter anitratus (1 case), Acinetobacter iwoffii (1 case) and Flavobacterium brevis (1 case); in one patient with Gram positive staining for gram-negative bacilli, the culture was negative, and three of them (20%) were mixed infections (Staphylococcus spp.). Three patients (20%) died. CONCLUSIONS: In adults, gram-negative bacilli rarely cause spontaneous meningitis, but are a common causation of post-neurosurgical meningitis and in those with neurosurgical devices. The mortality rate of MGNB is high.