Factores pronósticos clínicos determinantes en la supervivencia de pacientes con el virus Ébola / Clinical prognostic factors determining the survival of patients with the Ebola virus

Introducción: La enfermedad por el virus del Ébola presenta una elevada letalidad, por lo cual resulta de gran interés la realización de investigaciones que aborden las manifestaciones clínicas que pudieran ser factores pronósticos de supervivencia. Objetivo: Evaluar factores pronósticos de los pacientes enfermos de ébola. Métodos: El universo lo constituyó la totalidad (n = 350) de pacientes ingresados. Se emplearon medidas de resumen para variables cualitativas, estimaciones puntuales y por intervalos para las cuantitativas, así como las pruebas de significación Kaplan-Meier, regresión de Cox y Odds Ratio. Se trabajó con un nivel de confiabilidad del 95 por ciento. Resultados: La supervivencia global fue del 42,5 por ciento. La media de supervivencia, de aproximadamente 10 días (IC: 9 - 11 días). Los pacientes que ingresaron en estado grave (OR = 3,76), que tuvieron dolor lumbar (OR = 2,24), que refirieron cefalea (OR = 2,22), que presentaron fiebre (OR=2,16), que aquejaron de dolor abdominal (OR=1,95) y a quienes se les constató inyección conjuntival (OR = 1,86), tuvieron mayor probabilidad de fallecer, que quienes ingresaron sin estos síntomas y signos. Conclusiones: La supervivencia fue elevada, pese a las complicaciones presentadas. Los síntomas y signos predictores de muerte en los pacientes fueron: la gravedad del paciente al momento del ingreso, la presencia de dolor lumbar, cefalea, fiebre, dolor abdominal e inyección conjuntival(AU)

Introduction: Ebola virus disease has a high lethality, which is why it is of great interest to carry out research that addresses clinical manifestations that could be prognostic factors for survival. Objective: To evaluate prognostic factors of Ebola patients. Methods: the universe was constituted by the totality (n = 350) of admitted patients. Summary measures were used for qualitative variables, point and interval estimates for quantitative variables, as well as Kaplan-Meier significance tests, Cox regression and Odds Ratio. We worked with a 95% level of reliability. Results: The overall survival was 42.5 por ciento. The average survival, approximately 10 days (CI: 9-11 days). Patients who were admitted in serious condition (OR = 3.76), who had low back pain (OR = 2.24), who reported headache (OR = 2.22), who presented fever (OR = 2.16), who they suffered from abdominal pain (OR = 1.95) and who were found to have conjunctival injection (OR = 1.86), were more likely to die than those who entered without these symptoms and signs. Conclusions: Survival was high, despite the complications presented. The symptoms and predictive signs of death in the patients were: the severity of the patient at admission, the presence of low back pain, headache, fever, abdominal pain and conjunctival injection(AU)

Multidisciplinary Perioperative Management of Pulmonary Arterial Hypertension in Patients Undergoing Noncardiac Surgery.

OBJECTIVES: To describe the effect of implementing a contemporary perioperative pulmonary hypertension (PH)-targeted protocol in patients with pulmonary arterial hypertension (PAH) undergoing noncardiac surgery (NCS). METHODS: The data of consecutive patients with PAH diagnosed by right heart catheterization who underwent NCS between January 1, 2006 and February 9, 2016 were reviewed. Patient demographics, etiology of PAH, clinical features, diagnostic data, utilization of PH-specific medications, and trend of perioperative complications rate were recorded during the study period. RESULTS: In the base cohort of 375 patients, 37 had NCS. The mean age at surgery was 62 years. Most patients were women (78%) classified in group 1 PAH. At the time of the surgery, 86% were New York Heart Association functional class III/IV and 97% had American Society of Anesthesiologists classifications 3 and 4. A larger proportion of patients displayed lower PAH risk scores between 2006 and 2011 (P = 0.045). Conversely, a higher percentage of patients exhibited moderately high to very high PAH risk scores between 2012 and 2016 (P = 0.003). Perioperative and anesthetic-related morbidity was 27%, and no difference was observed between either period (P = 0.944). Most of the complications (70%) were related to general anesthesia. Two deaths (5%) occurred in our study group, both during the 2006-2011 period. CONCLUSIONS: The combination of a multidisciplinary perioperative approach, utilization of novel pulmonary vascular disease-targeted therapy, adequate perioperative optimization, and thoughtful selection of anesthetic technique seems to be a potential strategy to at least maintain similar perioperative outcomes among higher- and lower-risk patients with PAH undergoing NCS.

Oxygen Therapy with High-Flow Nasal Cannula as an Effective Treatment for Perioperative Pneumocephalus: Case Illustrations and Pathophysiological Review.

Pneumocephalus (PNC) is a condition in which when air is trapped inside the intracranial vault. The causes are varied, but include trauma and intracranial surgery. Treatment of PNC typically consists of augmenting patient oxygenation with the attempt of washing out pulmonary nitrogen, creating a gradient in which nitrogen in the intracranial air bubble diffuses out of the lungs via the blood. Though several high flow methods have been tested, the ideal mode of oxygenation has not fully been investigated. Here we present 3 cases of post-operative PNC who we felt were symptomatic from PNC. With administration of high-flow nasal cannula (HFNC), all patients improved both clinically and radiographically within a few hours, faster than in both anecdotal experience and published trials. Due to its steady FiO2 administration, positive pressure, comfort, and low side-effect profile, HFNC may be the ideal mode of oxygen delivery in PNC. We present a review of the physiology of PNC and the characteristics of several oxygen delivery systems to build a case for HFNC in this disease process.

Non-atherosclerotic aortic mural thrombus: a rare source of embolism.

A 54-year-old man presented to the emergency department with acute left-sided chest pain and left upper quadrant abdominal pain. He had a significant history of squamous cell carcinoma of the lung previously treated with right pneumonectomy who ; is currently receiving adjuvant chemotherapy with cisplatin. Physical examination was remarkable for tachycardia, hypertension and mild abdominal tenderness. CT angiography revealed an aortic mural thrombus in the ascending aorta and aortic arch without dissection, aneurysm or tortuosity of the aorta. In addition, an infarction of the inferior spleen was reported. Given the high risk of surgery for this patient, he was treated conservatively with esmolol and heparin infusion. His subsequent hospital course was uneventful, and he was successfully discharged on enoxaparin therapy that was successively bridged to rivaroxaban treatment. Follow-up transesophageal echocardiography and CT angiography at one month showed no thrombus in the aorta.

Respiratory variation in carotid peak systolic velocity predicts volume responsiveness in mechanically ventilated patients with septic shock: a prospective cohort study.

BACKGROUND: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. METHODS: We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter. RESULTS: Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77-0.95); followed by stroke volume variation (0.72, 95 % CI 0.63-0.88), passive leg raising (0.69, 95 % CI 0.56-0.80), and pulse pressure variation (0.63, 95 % CI 0.49-0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001). CONCLUSIONS: ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.

Impact of a focused transthoracic echocardiography training course for rescue applications among anesthesiology and critical care medicine practitioners: a prospective study.

OBJECTIVE: To investigate the impact of a sequence of educational interventions in a one-day course on focused transthoracic echocardiography (FOTE) by anesthesia and critical care practitioners. DESIGN: A prospective analysis of the educational data. SETTING: Educational setting in two academic medical centers and a medical meeting workshop organized by one of these institutions. PARTICIPANTS: Fifty-six anesthesia and critical care providers, divided into three groups, participated separately in a FOTE training course. INTERVENTIONS: All participants received a sequence of educational intervention as follows: A standardized, multiple-choice pretest; a lecture on cardiac and lung ultrasound; and a FOTE "hands-on" training session. The same standardized test was administered and graded as a posttest. MEASUREMENTS AND MAIN RESULTS: Fifty-six professionals attended the course in three separate groups: The first were cardiothoracic anesthesia fellows (n = 16) (group 1), the second included critical care practitioners (n = 21) (group 2), and the third were general anesthesiologists (n = 19) (group 3). Parasternal views were most difficult to obtain for all groups (58.1, 63.8, and 58%, respectively). The mean written test scores increased from 14.9±2 to 21.0±2.3 in group 1; from 12.3±3.8 to 19.2±3.7 in group 2; 12±3.5 to 21±2.4 in group 3, (p = 0.0003, 0.00005, 0.0001, respectively). CONCLUSIONS: A FOTE training course improves image acquisition skills and knowledge to the same level independently of professional background and level of experience in critical care ultrasound.

Relaciones entre el autoconcepto relacional, la elección de metas y la satisfacción de necesidades psicológicas en estudiantes universitarios / Relations between the Relational Self-Construal, the Choice of Goals and Psychological Need Satisfaction of University Students

El objetivo de este trabajo fue estudiar cómo ciertas características del autoconcepto pueden influir en la elección de unas u otras metas en estudiantes universitarios. Se utilizó una adaptación al castellano de la escala Relational-Interdependent Self-Construal ([RISC]; Cross, Bacon, & Morris, 2000) para medir el grado en el que los estudiantes incorporan sus relaciones interpersonales significativas en la construcción del autoconcepto. En una muestra de 389 universitarios españoles (rango de edad 16-47, M = 19.28; DE = 3.15) se efectuaron distintos contrastes que mostraron diferencias significativas asociadas al género ($ = 59% y S = 41% con tamaños de efecto d 0.25-0.55) y a las puntuaciones (altas frente a bajas, d 0.42-0.91) en la escala del RISC. Asimismo, esta variable de diferencias individuales apareció como predictora significativa en la elección de determinado tipo de metas y de la satisfacción de las necesidades psicológicas de autonomía, competencia y vinculación. Estos resultados tienen implicaciones en la elección de estudios y en lo que los estudiantes esperan encontrar en la universidad.

The aim of this study was to explore the role of specific features of the self-concept that could be associated with the choice of life goals. We developed an adaptation of the RISC (Relational-Interdependent Self-Construal; Cross, Bacon, & Morris 2000) to directly assess the degree to which individuals define themselves in terms of close relationships. The scale was translated into Spanish and its psychometric properties were analyzed with data from a sample of 389 university students (age range 16-47, M = 19.28, ST=3.15). A set of contrast showed significant differences between men and women ($=59% y S= 41% effect size d 0.25-0.55). Significant differences appeared also regarding extrinsic and intrinsic goals, interpersonal goals and needs satisfaction when students with a highly relational self-construal were compared with students with a low relational one (d 0.42-0.91). These results have implications for the choice of studies and what students expect in university life.

Mortalidad y readmisión en la unidad de cuidados intensivos / Mortality and readmission to the intensive care unit

INTRODUCCIÓN: la readmisión en las unidades de cuidados intensivos durante la hospitalización se asocia con una significativa mortalidad y un incremento de la estadía y los costos, por lo que existe un creciente interés en identificar los elementos predictores de la readmisión. OBJETIVO: caracterizar las readmisiones y la mortalidad asociadas a factores de riesgo en la Unidad de Cuidados Intensivos Polivalente del Hospital Militar Central "Dr. Carlos J. Finlay". MÉTODOS: estudio descriptivo, longitudinal y retrospectivo, entre el 1ro. de enero al 31 de diciembre de 2008. La muestra estuvo constituida por todos los pacientes readmitidos en el periodo señalado. Se aplicó el estadígrafo t de Student para las variables edad, estadía hospitalaria al ingreso, readmisión o egreso. RESULTADOS: predominaron los pacientes del sexo masculino mayores de 40 años. Hubo un 37,8 % de mortalidad global, principalmente de fallecidos en entidades clínicas. Los pacientes con mayor período entre ingreso-readmisión, presentaron una elevada mortalidad. La sepsis respiratoria fue la causa más frecuente de readmisiones. La tasa de readmisión fue de 3,31 %. CONCLUSIÓN: la escala APACHE II constituyó un adecuado predictor de riesgo de morir en la Unidad de Cuidados Intensivos. Las variables con impacto sobre la mortalidad fueron edad, sexo masculino, ventilación mecánica y la presencia de enfermedades clínicas. La tasa de readmisiones se comportó por debajo de la media internacional, lo que evidencia un buen trabajo de la Unidad de Cuidados Intensivos en este indicador de calidad.

INTRODUCTION: reentry to the ICU during hospitalization is associated with significant mortality and an increase of stay and costs, so that there is a growing interest in identifying predictors of readmission elements. OBJECTIVE: to characterize reentries and mortality associated to risk factors in the Intensive Care Unit at "Dr. Carlos J. Finlay" Central Military Hospital. METHODS: a descriptive, longitudinal and retrospective study was conducted from January 1st December to 31st 2008. The sample consisted of all patients readmitted within the given period. The Student t statistic for the variables such as age, hospital admission, hospital stay, hospital readmission or discharge was applied. RESULTS: male patients over 40 years were in majority. There was 37.8 % overall mortality, mainly of deaths in clinical entities. Patients with higher admission- readmission period showed a high mortality. Respiratory sepsis was the most frequent cause of readmissions. The readmission rate was 3.31 %. CONCLUSION: APACHE II scale is an adequate predictor of risk of deceases in ICU. Variables with impact on mortality were age, male gender, mechanical ventilation, and the presence of clinical disease. The rate of readmissions was below the international average, which demonstrates good performance of ICU in this quality indicator.

A case series discussing the anaesthetic management of pregnant patients with brain tumours.

Pregnancy may aggravate the natural history of an intracranial tumour, and may even unmask a previously unknown diagnosis. Here we present a series of seven patients who had brain tumours during pregnancy. The aim of this case series is to characterize the current perioperative management and to suggest evidence based guidelines for the anaesthetic management of pregnant females with brain tumours. This is a retrospective study. Information on pregnant patients diagnosed with brain tumours that underwent caesarean section (CS) and/or brain tumour resection from May 2003 through June 2008 was obtained from the Department of General Anaesthesia and the Rose Ella Burkhardt Brain Tumour & Neuro-Oncology Centre (BBTC) at the Cleveland Clinic, OH, USA. The mean age was 34.5 years (range 29-40 years old). Six patients had glioma, two of whom had concomitant craniotomy and CS. Six cases had the tumour in the frontal lobe. Four cases were operated on under general anaesthesia and three underwent awake craniotomy. The neonatal outcomes of the six patients with elective or emergent delivery were six viable infants with normal Apgar scores. Pregnancy was terminated in the 7th patient. In conclusion, good knowledge of the variable anesthetic agents and their effects on the fetus is very important in managing those patients.

Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope.

STUDY OBJECTIVES: To determine whether the first-attempt tracheal intubation incidence using the GlideScope videolaryngoscope is higher in patients with predicted increased risk of difficult laryngoscopy, and to assess the ability of other a priori defined standard risk factors to predict first-attempt intubation success, in aggregate and by forming scores. DESIGN: Prospective study. SETTING: Operating room in a tertiary-care academic center. PATIENTS: 357 patients intubated with the GlideScope for nonemergent general anesthesia. INTERVENTIONS AND MEASUREMENTS: Mallampati airway class was used to create two groups of patients, one with higher and the other, lower, potential difficult laryngoscopy (Mallampati classes 3-4 and 1-2, respectively). Intubation success on the first attempt with the GlideScope videolaryngoscope in patients with a Mallampati class 3 or 4 airway versus those with Mallampati class 1 or 2 airway was tested. We also evaluated the predictive ability of the Mallampati airway class (1 and 2 vs 3 and 4) along with 9 other possible predictors of difficult intubation on first-attempt intubation success: gender, age, body mass index, level of training within our anesthesia residency program (Clinical Anesthesia Resident years 1, 2, and 3), ASA physical status, mouth opening, thyromental distance, neck flexion, and neck extension. MAIN RESULTS: None of the standard predictors of difficult intubation was significantly associated with outcome after adjusting for other predictors. A multivariable model containing the aggregate set of variables predicted outcome significantly better than a risk score formed as the sum of 10 predictors ("Risk 10"; P = 0.0176). CONCLUSIONS: With GlideScope-assisted tracheal intubation, Mallampati airway class is not an independent risk factor for difficult intubation. Other standard clinical risk factors of difficulty with direct laryngoscopy also do not appear to be individually predictive of first-attempt success of tracheal intubation.

Acute hypopituitarism in a pregnant patient after cardiac gunshot injury.

Sheehan's syndrome is a well described entity that refers to hypopituitarism with pituitary infarction secondary to postpartum shock or hemorrhage. Antepartum pituitary infarction is a very rare condition that has been reported only in patients with longstanding type 1 diabetes mellitus or uncontrolled gestational diabetes. A case of severe, acute hypopituitarism in the setting of hemorrhagic shock from a gunshot wound is presented. Our case report highlights the importance of including hypopituitarism in the differential diagnosis of a critically ill parturient.

The effect of postoperative gastrointestinal complications in patients undergoing coronary artery bypass surgery.

BACKGROUND: Gastrointestinal (GI) complications after coronary artery bypass graft surgery (CABG) are uncommon but associated with a disproportionate share of mortality. We thus identified variables associated with GI complications and analyzed their effect on postoperative mortality in patients undergoing isolated CABG. METHODS: Information from patients who underwent isolated CABG at our institution during a 12-year period was obtained from the Anesthesiology Institute patient registry. Patients who experienced one or more postoperative GI complication(s) during their initial intensive care unit stay were identified. Multivariable logistic regression with backward variable selection was used to determine variables associated with GI complications and to evaluate their effect on mortality. RESULTS: Among 16,043 patients who underwent isolated CABG, 213 (1.43%) had one or more GI complication(s). The main patient variables associated with postoperative GI complications included preoperative (odds ratio, 2.43; 95% confidence interval [CI], 1.39 to 4.23; p < 0.001) and intraoperative (odds ratio, 5.07; 95% CI, 3.08 to 8.35; p < 0.001) intraaortic balloon pump insertion, patient age (odds ratio, 1.65; 95% CI, 1.41 to 1.94; p < 0.001), intraoperative fresh-frozen plasma transfusion (odds ratio, 3.38; 95% CI, 2.12 to 5.41; p < 0.001), and cardiogenic shock (odds ratio, 3.04; 95% CI, 1.12 to 8.24). No difference was detected in complication rates between off-pump and on-pump CABG procedures (1.50% versus 1.30%, respectively; p = 0.63). Postoperative GI complication(s) after CABG was associated with a 12.98 times increase in mortality (p < 0.001). CONCLUSIONS: This single-center cohort study indicates that GI complications after isolated CABG remain rare with an incidence 1.43%. However, GI complications portend a significant mortality. The implications of intraoperative administration of fresh-frozen plasma and insertion of an intraaortic balloon pump deserve further investigation as they are associated with GI complications.

Realimentación oral en lactantes con marasmo sometidos a alimentación enteral con sonda nasogástrica continua / Reinstituting oral feeding in marasmic infants fed by nasogastric tube

Introducción. Se evaluó la adaptación a la ingesta de fórmula después de recibir alimentación enteral las primeras 2 semanas del tratamiento de lactantes con marasmo en fase de recuperación. Material y métodos. Trabajo retrolectivo de un ensayo clínico. La alimentación fue administrada por sonda nasogástrica durante 2 semanas y posteriormente con biberón. Se compararon los promedios semanales de ingesta por sonda vs oral y de incremento de peso con cada sujeto como su propio control.Resultados. Se incluyeron 12 lactantes con edad promedio de 189 días. El promedio de fórmula consumida fue 255, 256, 251, 239 mL/kg/día para las 4 semanas. Hubo diferencias al comparar la ingesta de las semanas 2 vs 4; la ganancia de peso fue mayor en la semana 1 al compararla con las semanas 3 y 4 y fue mayor en la semana 2 al compararla con la semana 3; sin embargo, todos los pacientes tuvieron recuperación nutricia satisfactoria. Conclusiones. En lactantes con marasmo la alimentación enteral durante las 2 primeras semanas de tratamiento asegura un aporte adecuado de energía y nutrimentos y no se asocia a reducción significativa en la ingesta posterior. Desnutrición; alimentación enteral; recuperación nutricia; incremento de peso.

Recuperación nutricia en lactantes con marasmo alimentados con fórmula láctea de inico o aislado de proteína de soya con incremento de la densidad energética / Nutritional recovery in nursing infants with marasmus fed with starting milk formula or isolated soy protein formula with increased energetic density

Introducción. Objetivo. comparar la recuperación nutricia del lactante con marasmo alimentado con fórmula láctea de inicio o aislado de proteína de soya e incremento de la densidad calórica. Material y métodos. En un ensayo clínico se incluyeron 12 lactantes con marasmo de 3 a 12 meses de edad, peso al nacer mayor de 2500g, sin otra alteración. Seis recibieron fórmula láctea de inicio y 6 fórmula de aisalado de proteína de soya adicionadas con 5 por ciento de miel de maíz. Durante 4 semanas se realizaron evaluaciones bioquímicas y antropométricas. Mediante la prueba de t de Student se rechazó la hipótesis nula con P menor de 0.05. Resultados. El incremento diario de peso fue de 63 y 58 g/día con fórmula láctea y soya respectivamente. No hubo diferencias significativas entre grupos al inicio y al final del estudio en los indicadores antropométricos, bioquímicos y hematológicos. Hubo mayor incremento en longitud en el grupo que recibió fórmula láctea de inicio. El grupo que recibió soya acumuló más grasa desde la primera semana. Conclusiones. Ambos grupos tuvieron una recuperación nutricia similar. La fórmula láctea de inico podría ser la mejor opción por su costo 2 a 3 veces menor