[Survival and neurological outcome in out-of-hospital cardiac arrests due to shockable rhythms treated with mild therapeutic hypothermia]. / Supervivencia y pronóstico neurológico en paradas cardiorrespiratorias extrahospitalarias por ritmos desfibrilables tratadas con hipotermia terapéutica moderada.

OBJECTIVE: To analyze survival and neurological outcome at short and medium term in patients treated with mild therapeutic hypothermia (HTM) in our hospital after suffering an out-of-hospital cardiac arrest (CA) secondary to a shockable rhythm. DESIGN: Prospective, observational study from September 1, 2010 to December 31, 2012, with a follow up of 6 months. SETTING: Tertiary hospital. PATIENTS: All patients who suffer an out-of-hospital CA due to shockable rhythms. EXCLUSION CRITERIA: non-shockable rhythms, resuscitation >45 minutes without pulse recovery, septic shock, previous coagulopathy, terminal illness or order for withholding treatment. INTERVENTION: Mild hypothermia (33°C) and postresuscitation care on the basis of standardized protocols. MAIN VARIABLES: Demographic and epidemiological data, CA data and survival and neurological outcome at hospital discharge and after 6 months. To assess the patients' neurological status, Cerebral Performance Categories (CPC) scale was used. RESULTS: A total of 54 patients were analyzed. 37 patients were discharged to hospital, representing a survival at discharge of 68.5%, which remains 6 months later because no discharged patient died during the follow up period. Regarding neurological outcome, 44.4% of patients were alive and with CPC 1-2 at discharge and up to 54.71% at 6 months. CONCLUSIONS: The results of survival and neurological functional status obtained in our center after implementation of HTM are comparable to those published in the literature.

[Serious mechanical complications associated with pulmonary artery catheters in cardiovascular and thoracic surgery]. / Complicaciones graves de tipo mecánico asociadas al catéter de arteria pulmonar en cirugía cardiovascular y torácica.

OBJECTIVE: Although the use of pulmonary artery catheters (PACs) in managing critical patients is a subject of debate, they continue to be inserted in many cases and possible complications should be taken into account. Our objective was to review the serious or potentially serious complications associated with PACs in our hospital in the past 15 years. PATIENTS AND METHODS: This was a retrospective study of seious mechanical complications of PAC use in patients who underwent vascular, cardiac, and thoracic surgery. RESULTS: The study included the records 7540 patients; 9 cases of serious complications were detected. These complications included 5 cases of pulmonary artery rupture (3 of which resulted in death), 1 perforated internal mammary vein, 1 knotted catheter, 1 bent one, and 1 case of a PAC becoming trapped in the surgical suture. CONCLUSIONS: The 0.12% incidence of complications is lower than rates found in the literature. Although these complications are rare, it is necessary to take precautions against their unexcepted appearance by carefully selecting the patients in whom PACs are placed and by paying special attention to the characteristic clinical and radiological signs of complications.

[Behaviour of near-infrared cerebral oximetry readings during percutaneous carotid angioplasty]. / Valoración del comportamiento de la oximetría cerebral por infrarrojos durante la angioplastia percutánea de carótida interna.

BACKGROUND: Transluminal percutaneous carotid angioplasty and stenting (CAS) carries a risk of cerebral ischemia, hemorrhage, or edema due to relative hyperemia and hemodynamic instability during and after the procedure. Noninvasive monitoring of near-infrared regional cerebral oxygen saturation (SrO2) offers an indirect way to estimate cerebral blood flow. OBJECTIVE: To evaluate the behaviour of SrO2 during CAS and the usefulness of this variable for continuous monitoring of cerebral blood flow variation and neurological status. MATERIAL AND METHODS: Prospective study of 25 patients scheduled for unilateral CAS under monitored anesthesia care. SrO, and other hemodynamic and clinical data were recorded. A change in SrO2 (deltaSrO2) of 15% or more in comparison with the baseline value and lasting more than 30 seconds was considered clinically significant. Neurological complications in the first 24 hours were also registered. RESULTS: Baseline SrO, ranged from 51% to 75%. With administration of papaverine SrO2 values increased by a mean (SD) of 5.6% (6%) (P<.05 vs baseline). They decreased during angioplasty, -2.5% (5.7%) (P<.05 vs baseline), increased after 5 minutes, and fell again at 30 minutes to a level 3% (6.54%) above baseline. Two patients showed signs of elevated intracranial pressure after the procedures and also had ASrO2 readings exceeding 15%; measures to lower arterial hypertension reduced SrO2 in these patients. CONCLUSION: High interindividual variability of absolute SrO2 values has been confirmed. SrO, fluctuates with maneuvers that change cerebral blood flow in the same way. Changes can precede the onset of other clinical signs.

[Cardiopulmonary resuscitation in hospitalized patients in conventional units. Prospective study of 356 consecutive cases. Commission for Care of Cardiorespiratory Arrest]. / Reanimación cardiopulmonar en enfermos hospitalizados en unidades convencionales. Estudio prospectivo de 356 casos consecutivos. Comisión de Atención al Paro Cardiorrespiratorio.

BACKGROUND: Information regarding to the system functioning and to the outcome of patients in whom cardiopulmonary resuscitation (CPR) was performed during their in hospital period in non intensive care units are essentially lacking in Spain. The objectives of the present work were: 1) to define clinical and demographic characteristics of the patients who develop cardiopulmonary arrest in general hospitalization wards; 2) to analyze immediate and late (at discharge) survival rates as well as the frequency of severe sequelae in final survivors; 3) to identify prognostic factors in relationship to survival, and 4) to detect possible internal deficiencies in the organized system of CPR. PATIENTS AND METHODS: All patients who develop cardiac and pulmonary arrest through their hospitalization in general wards during a three year period, were prospectively included. Clinical and demographic data from all the patients as well as data related to the internal functioning of the system were recorded. RESULTS: From 356 included cases, 196 (55%) were initially recovered and 128 (36%) were discharged from the hospital. Among the latter group, 12.5% remained with severely disabling neurologic damage. Age under 80 years, resuscitation maneuvers for less than 20 minutes and respiratory arrest as the ultimate event leading to cardiopulmonary arrest were associated with better prognosis. The internal deficiencies most commonly recorded in the system were false calling to the emergency team, the wrong identification of the location in the hospitalization unit and several abnormalities in the content of CPR sets. CONCLUSIONS: With the currently available organized system directed towards CPR for patients admitted in general hospitalization wards, our rates of success are good and similar to those achieved in some intensive care units. Thus, a similar policy may be encouraged in large hospitals. Since most of the detected deficiencies in internal functioning are easy to rectify, a close monitoring is warranted in order to optimize the results.

[Cardiac tamponade following sternal puncture. Usefulness of ultrasound focussed assessment with sonography for trauma]. / Taponamiento cardíaco tras punción esternal. Utilidad de la ecografía focussed assessment with sonography for trauma.

One of the aims of the medical profession is to be able to detect complications in patients during diagnostic tests and treatments. The early diagnosis of these complications can prevent a fatal outcome. The diagnosis is often based on clinical symptoms and supported by complementary tests. Diagnostic tests have been developed in the last few years that are rapid and easy to use, as well as being cost effective and minimally invasive. Focussed assessment with sonography for trauma ultrasound (echo-FAST) was introduced in the 1990s in the field of resuscitation as a test for the rapid detection of intra-abdominal and pericardial fluid in multiple injury patients, but its uses in other cases not involving trauma still raise doubts and controversy. A case is presented of a patient subjected to a sternal puncture for a bone marrow aspirate, who had a complication of a secondary cardiac tamponade, which was diagnosed early using echo-FAST.

Dobutamine restores intestinal mucosal blood flow in a porcine model of intra-abdominal hyperpressure.

OBJECTIVE: To assess the effects of dopamine and dobutamine administration on the systemic and mesenteric (macro- and microvascular) circulatory disturbances induced by intra-abdominal hyperpressure. DESIGN: Prospective, randomized study. SETTING: Animal research laboratory in a university hospital. SUBJECTS: Twenty-five pigs of either gender, weighing 30-35 kg. INTERVENTIONS: Animals were anesthetized, and their lungs were mechanically ventilated. Pulmonary artery flotation and carotid artery catheters were inserted for hemodynamic monitoring and blood sampling. A perivascular flow probe was placed around the superior mesenteric artery, and a laser Doppler probe was positioned in the lumen of the ileum to measure arterial and intestinal mucosal blood flows, respectively. CO2 was insufflated into the peritoneal cavity to reach an intra-abdominal pressure of 15 mm Hg, and 60 mins later, animals received dopamine (5 microg/kg/min; n = 10), dobutamine (5 microg/kg/min; n = 10), or saline (n = 5) for 30 mins. MEASUREMENTS AND MAIN RESULTS: Peritoneal CO2 insufflation induced significant increases in heart rate, arterial pressure, and systemic vascular resistance with concomitant decreases in cardiac output and superior mesenteric arterial and intestinal mucosal blood flows. Although dobutamine infusion reversed the decrease in cardiac output, it failed to restore superior mesenteric artery blood flow; however, intestinal mucosal blood flow returned to baseline levels. Dopamine also attenuated the decrease in cardiac output, but it had no beneficial effect on splanchnic hemodynamic variables. CONCLUSIONS: Low-dose infusion of dobutamine, but not dopamine, corrects the intestinal mucosal perfusion impairment induced by moderate increases in intra-abdominal pressure.

Helium and carbon dioxide pneumoperitoneum in patients with pheochromocytoma undergoing laparoscopic adrenalectomy.

Insufflation with helium is used to prevent respiratory acidosis, hypercapnia, and cardiovascular instability associated with carbon dioxide (CO2) pneumoperitoneum. The aim of this prospective study was to compare CO2 with helium pneumoperitoneum with special reference to respiratory and hemodynamic changes at different times during the operation. Altogether 22 pheochromocytoma patients undergoing laparoscopic adrenalectomy (LpA) were included using CO2 in 11 patients (CO2LpA) and helium in 11 patients (HeLpA). The insufflation pressure was 12 mmHg. The two groups were comparable with regard to demographic data and preoperative management. CO2 and helium insufflation were associated with similar catecholamine increase. The most striking significant increase compared with the baseline was observed during tumor isolation: The mean plasma epinephrine (EPI) and norepinephrine (NE) levels increased 32.86-fold and 25.92-fold, respectively, in the CO2LpA patients and 27.43-fold and 18.46-fold, respectively, in the HeLpA patients. HeLpA did not result in significant hypercarbia or acidosis at any measured intraoperative point; this was without any alteration in minute ventilation to maintain these normal PaCO2, excess base (EB), and pH values. Significant increases of mean arterial pressure, pulmonary arterial pressure, pulmonary vascular resistance index, PaCO2, EB, and acidosis were seen in the CO2LpA patients at the time of tumor isolation and tumor removal compared with those in HeLpA patients. No patient required conversion to open surgery. There were no significant differences between CO2LpA and HeLpA regarding mean operative time (117.50 +/- 93.68 vs. 106.87 +/- 16.60 minutes), mean blood loss (168.54 +/- 78.63 vs. 142.02 +/- 109.26 ml), hospital stay (4 days), the need for analgesics, or mean time required to return to normal activity (12 days). There was one wound infection in the HeLpA group and one wound hematoma and one case of atelectasis in the CO2LpA group. Helium may be the agent of choice for abdominal insufflation in patients undergoing LpA for pheochromocytoma, eliminating the adverse hemodynamic and respiratory changes associated with CO2 insufflation.

Effects of carbon dioxide vs helium pneumoperitoneum on hepatic blood flow.

BACKGROUND: Elevated intraabdominal pressure due to gas insufflation for laparoscopic surgery may result in regional blood flow changes. Impairments of hepatic, splanchnic, and renal blood flow during peritoneal insufflation have been reported. Therefore we set out to investigate the effects of peritoneal insufflation with helium (He) and carbon dioxide (CO2) on hepatic blood flow in a porcine model. METHODS: Twelve pigs were anesthetized and mechanically ventilated with a fixed tidal volume after the stabilization period. Peritoneal cavity was insufflated with CO2 (n = 6) or He (n = 6) to a maximum intraabdominal pressure of 15 mmHg. Hemodynamic parameters, gas exchange, and oxygen content were studied at baseline, 90 mm and 150 min after pneumoperitoneum, and 30 min after desufflation. Determination of hepatic blood flow with indocyanine green was made at all measured points by a one-compartment method using hepatic vein catheterization. RESULTS: A similar decrease in cardiac output was observed during insufflation with both gases. Hepatic vein oxygen content decreased with respect to the baseline during He pneumoperitoneum (p < 0.05), but it did not change during CO2 insufflation. Hepatic blood flow was significantly reduced in both the He and CO2 pneumoperitoneums at 90 min following insufflation (63% and 24% decrease with respect to the baseline; p < 0.001 and p < 0.05, respectively) being this decrease marker in the He group (p = 0.02). CONCLUSIONS: These findings suggest that helium intraperitoneal insufflation results in a greater impairment on hepatic blood flow than CO2 insufflation.