Mesenchymal Stem Cells for the Compassionate Treatment of Severe Acute Respiratory Distress Syndrome Due to COVID 19.

Mesenchymal stem cells (MSC) have received particular attention due to their ability to inhibit inflammation caused by cytokine storm induced by COVID-19. In this way some patients have been treated successfully. The aim of this study was to evaluate the safety and describe the clinical changes after IV administration of allogeneic human umbilical cord MSC (ahUCMSC), in patients with bilateral pneumonia caused by COVID-19, complicated with severe ARDS, as compassionate treatment. This was a pilot, open-label, prospective, longitudinal study. Five patients that did not improve in their clinical conditions after 48 hours of receiving the standard medical management used by the Medical Center and with persistent PaO2/FiO2 less than 100 mmHg were enrolled. ahUCMSC were infused IV, at dose of 1x106 per Kg of body weight over 15 minutes. Patients were monitored after the infusion to detect adverse event. Pa02/FiO2, vital signs, D-dimer, C reactive protein and total lymphocytes were monitored for 21 days after the infusion or until the patient was discharged from the hospital. Descriptive statistics were used with means or medians and standard deviation or interquartile range according to the type of variable. The Wilcoxon's rank-sum was used for stationary samples. Adverse events occurred in three patients and were easily and quickly controlled. Immediately after the infusion of ahUCMSC, constant rise of PaO2/FiO2 was observed in all patients during the first 7 days, with statistical significance. Three patients survived and were extubated on the ninth day post-infusion. Two patients died at 13 and 15 days after infusion. The infusion of ahUCMSC in patients with severe ARDS caused by COVID-19, was safe, and demonstrated its anti-inflammatory capacity in the lungs, by improving the respiratory function expressed by PaO2 / FiO2, which allowed the survival of 3 patients, with extubation at 9 days.

Impacto de las asincronías en el pronóstico del paciente bajo ventilación mecánica invasiva / Prognosis impact of the asynchronies in the mechanical ventilated patient / Impacto das assincronias no prognóstico do paciente com ventilação mecânica invasiva

Resumen: La ventilación mecánica es común en pacientes críticos. La asincronía paciente-ventilador existe cuando las fases de la respiración administradas por el ventilador no coinciden con las del paciente. Las asincronías son frecuentes e infradiagnosticadas, éstas se han asociado con desenlaces desfavorables como son: mayor duración de ventilación mecánica, estancia en la unidad de terapia intensiva, mortalidad, incomodidad del paciente, alteraciones del sueño y disfunción diafragmática. Esta revisión describe los desenlaces adversos reportados que se han asociado a la presencia de asincronías en pacientes adultos bajo ventilación mecánica invasiva. La evidencia actual sugiere que el mejor enfoque para manejar las asincronías es ajustar la configuración del ventilador y mejorar su detección. Si bien la mayoría de la evidencia proviene de estudios observacionales y ensayos clínicos aleatorizados realizados en poblaciones heterogéneas y con un número limitado de pacientes, los resultados sugieren desenlaces desfavorables clínicamente significativos en los pacientes que experimentan un índice de asincronía elevado. Por lo anterior, es necesario generar mayor evidencia en este tópico.

Abstract: Mechanical ventilation is common in critically ill patients. Patient-ventilator asynchrony exists when the breathing phases administered by the ventilator do not match those of the patient. They are frequent but underdiagnosed, and have been associated with worse outcomes because they negatively affect patient comfort, length of mechanical ventilation, length of stay in the intensive care unit and mortality. This review describes the negative outcomes associated with the presence of asynchronies in adult patients with invasive mechanical ventilation. Current evidence suggests that the best approach to handle asynchronies is to adjust the fan settings and improve the quality of detection. While most of this evidence comes from observational studies and randomized clinical trials which were done with heterogeneous populations and a limited number of patients, the results suggest less favorable clinically significant outcomes in patients with asynchronies. So it is necessary to generate more evidence in this topic.

Resumo: A ventilação mecânica é comum em pacientes críticos. A assincronia paciente-ventilador existe quando as fases da respiração fornecida pelo ventilador não coincidem com as do paciente. As assincronas são frequentes e subdiagnosticadas, tendo sido associadas a desfechos desfavoráveis como: maior tempo de ventilação mecânica, permanência em unidade de terapia intensiva, mortalidade, desconforto do paciente, distúrbios do sono e disfunção diafragmática. Esta revisão descreve os resultados adversos relatados que foram associados à presença de assincronia em pacientes adultos sob ventilação mecânica invasiva. A evidência atual sugere que a melhor abordagem para gerenciar assincronias é ajustar as configurações do ventilador e melhorar a detecção do ventilador. Embora a maioria das evidências provenha de estudos observacionais e ensaios clínicos randomizados conduzidos em populações heterogêneas e com um número limitado de pacientes, os resultados sugerem resultados clinicamente desfavoráveis significativos em pacientes que apresentam uma alta taxa de assincronia. Portanto, é necessário gerar mais evidências sobre este tema.

Manejo perioperatorio de paciente con COVID-19 / Perioperative management of the patient with COVID-19

Resumen: En la actualidad, la pandemia de SARS-CoV-2 ha puesto a prueba los sistemas de salud en toda su extensión a lo largo del mundo. Se desconoce el impacto del estrés quirúrgico y de la anestesia sobre la predisposición a una nueva infección por COVID-19, o la exacerbación de la infección en un paciente infectado por este virus que se va a operar. Aunque la mortalidad de COVID-19 está entre 1-5%, la mayoría de las muertes han ocurrido en pacientes de edad avanzada con afecciones cardiopulmonares subyacentes, la mayoría de ellos hipertensos, diabéticos y con obesidad, por lo cual, se debe poner especial atención en su manejo. La preparación y planeación perioperatoria cuidadosa es clave para lograr con éxito una adecuada atención clínica y mantener la seguridad del equipo de salud en un momento difícil y de alto riesgo. Un papel adicional del anestesiólogo, considerando que es el médico con mayor experiencia en el manejo de la vía aérea, consiste en apoyar a los servicios de emergencia para la intubación endotraqueal de los pacientes que requieren apoyo ventilatorio, siendo un procedimiento con recomendaciones de protección muy específicas. Por lo tanto, existe un compromiso como especialistas de conocer el tema a fondo y protegernos, así como al equipo de profesionales de la salud que se exponen salvando vidas durante esta contingencia.

Abstract: Currently, the SARS-CoV-2 pandemic has put health systems to the test throughout their world. The impact of surgical stress and anesthesia on predisposition to a new COVID-19 infection or exacerbation of the infection in a COVID-19 infected patient to be operated on is unknown. Although COVID-19 mortality is between 1-5%, most deaths have occurred in elderly patients with underlying cardiopulmonary conditions, most of them hypertensive, diabetic and obese, therefore, it should be specially attention in its handling. Carefull perioperative preparation and planning is key in successfully achieving adequate clinical care and maintaining the safety of the health team in a difficult and high risk moment. An additional role for the anesthesiologist, considering that he has the most experience in the management of the airway, is to support the emergency services for endotracheal intubation of patients who require ventilatory support, being a procedure with very specific protection recommendations. Therefore, there is a commitment as specialists, to know the subject thoroughly and protect ourselves along with the health team involved in saving lives during this contingency.

Clinical and epidemiological characteristics of patients diagnosed with covid-19 in a tertiary care center in Mexico City: a prospective cohort study

ABSTRACT Background: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Recomendaciones de tratamiento para pacientes adultos graves con COVID-19 / Recommendations for the management of critically ill adult patients with COVID-19

Resumen Con excepción de las mujeres embarazadas, el manejo de los pacientes adultos graves con COVID-19 durante la pandemia incluye los procedimientos estándar que se llevan a cabo en cualquier paciente que requiere atención en la unidad de cuidados intensivos, así como la administración limitada de las soluciones cristaloides, la intubación orotraqueal, la ventilación mecánica invasiva ante deterioro clínico del paciente y la relajación muscular en infusión continua solo cuando sea necesaria. No se recomienda la ventilación mecánica no invasiva, la oxigenoterapia de alto flujo debido a la generación de aerosol (asociado con riesgo de propagación del virus entre el personal de salud), la oxigenación por membrana extracorpórea ni el empleo de esteroides. Hasta el momento no hay tratamiento antiviral específico para pacientes con COVID-19 ni resultados de estudios controlados que avalen su uso.

Abstract Except for pregnant women, the management of critically ill patients with COVID-19 during the pandemic includes the standard procedures that are used for any patient that requires to be attended to at the intensive care unit, as well as limited administration of crystalloid solutions, orotracheal intubation, invasive mechanical ventilation in the event of patient clinical deterioration, and muscle relaxants continuous infusion only if necessary. Non-invasive mechanical ventilation and high-flow oxygen therapy are not recommended due to the generation of aerosol (associated with risk of viral spread among health personnel), and neither is extracorporeal membrane oxygenation or the use of steroids. So far, there is no specific antiviral treatment for patients with COVID-19, and neither are there results of controlled trials supporting the use of any.

Choque cardiogénico: de la definición al abordaje / Cardiogenic shock: from definition to the approach / Choque cardiogênico: da definição à abordagem

Resumen: El choque cardiogénico es la mayor catástrofe del infarto agudo al miocardio y de las cardiopatías en general. Se define como un estado en el cual el gasto cardiaco es ineficiente para perfundir y oxigenar los tejidos, por lo que se manifiesta con signos de hipoperfusión tisular y congestión capilar. Aunque las últimas guías no exijan el diagnóstico por medio de medidas hemodinámicas, el basarse sólo en lo clínico puede generar errores hasta en 30%. Las causas se dividen en isquémicas y no isquémicas, siendo la primera la más común. Pese a la aparición de nuevos dispositivos mecánicos, aunados al soporte médico, sólo se ha demostrado la mejora de los desenlaces con las terapias endovasculares.

Abstract: Cardiogenic shock (CSh) is the major catastrophe of acute myocardial infarction (AMI) and heart disease in general. It is defined as a state in which cardiac output (CO) is inefficient to perfuse and oxygenate tissues, which is why it manifests with signs of tissue hypoperfusion and capillary congestion. Although the latest guidelines do not require diagnosis with hemodynamic measures, relying only on the clinical can generate errors up to 30%. The causes are divided into ischemic (AMI) and non-ischemic, with the former being the most common. Despite the appearance of new mechanical devices, coupled with medical support, it has only shown the improvement of outcomes with endovascular therapies.

Resumo: O choque cardiológico (ChC) é a principal catástrofe do infarto agudo do miocárdio (IAM) e das cardiopatias em geral. Definida como um estado no qual o débito cardíaco (DC) é ineficiente para perfundir e oxigenar os tejidos, razão pela qual se manifiesta com sinais de hipoperfusão tecidual e congestão capilar. Embora as diretrizes mais recentes não exijam diagnóstico por meio de medidas hemodinâmicas, depender apenas da clínica pode gerar erros de até 30%. As causas são divididas em isquêmicas (IAM) e não isquêmicas, sendo a primeira a mais comum. Apesar do surgimento de novos dispositivos mecânicos aliados ao suporte médico, só demonstrou-se a melhora dos resultados com terapias endovasculares.

A 50-Year-Old Woman With Uterine Myomatosis, Rapidly Progressive Dyspnea, and Lower Extremity Edema.

CASE PRESENTATION: A 50-year-old woman with morbid obesity (BMI, 49 kg/m2) was admitted to the ED due to shortness of breath triggered by mild to moderate efforts over the previous 3 weeks that rapidly progressed to dyspnea at rest and became associated with oppressive chest pain and edema of the lower extremities. Four months prior to admission, she had been diagnosed with a uterine mass (18 × 21 cm2) suggestive of a leiomyoma, manifesting with abnormal vaginal bleeding and microcytic hypochromic anemia (Fig 1).

A 44-Year-Old Woman With Sudden Breathlessness, Tightness in Chest, and Hypotension After Extubation in the Early Postoperative Period After Liver Transplantation.

CASE PRESENTATION: A 44-year-old woman with Child-Pugh class C cirrhosis due to primary biliary cirrhosis and mild portopulmonary syndrome received a liver transplant. Her basal catheterization showed a mean pulmonary arterial pressure (mPAP) of 28 mm Hg, pulmonary artery occlusion pressure (PAOP) of 8 mm Hg, pulmonary vascular resistance (PVR) of 307 dynes.s.cm-5, and a cardiac output of 5.2 L/min. The echocardiogram did not reveal right ventricular dilatation (mid-diameter of 34 mm). In surgery, hemodynamic assessment showed an mPAP of 25 mm Hg, PAOP of 6 mm Hg, PVR of 262 dynes.s.cm-5 and cardiac output of 5.8 L/min. During the anhepatic period, the patient required norepinephrine (0.4 µg/kg/min) but had no complications during reperfusion; throughout surgery, her mPAP was never > 30 mm Hg. At the end of surgery, the brain natriuretic peptide level was 66 pg/mL (< 100 pg/mL). One day following transplantation, the patient remained hemodynamically stable and was therefore weaned from mechanical ventilation. However, 6 h following extubation, she reported breathlessness and tightness in chest, and developed sudden arterial hypotension, oxygen desaturation, and oliguria.

Modelos de reanimación en la terapia intensiva y desarrollo de complicaciones en el postoperatorio de trasplante hepático / Resuscitation models for liver transplantation at the intensive care unit and the development of postoperatory complications / Modelos de reanimação na terapia intensiva e desenvolvimento das complicações pós-operatórias em transplante hepático

Resumen: El periodo de reanimación después del trasplante hepático ortotópico (THO) es un desafío debido a las alteraciones fisiológicas relacionadas con la enfermedad hepática terminal (EHT). Material y métodos: Este es un estudio retrospectivo que evalúa las primeras 48 horas de manejo en la unidad de cuidados intensivos (UCI) de un hospital de la Ciudad de México. Los pacientes se clasificaron en 4 grupos según la dosis de norepinefrina (NADR) utilizada y el balance neto de líquidos (BalT): Grupo 1 norepinefrina menos de 0.1 μg/1 kg/min/BalT 3,805 ml, grupo 2 norepinefrina mayor de 0.1 μg/kg/min/BalT menos de 3,805 ml, grupo 3 norepinefrina menos de 0.1 μg/kg/min/BalT mayor de 3,805 ml, grupo 4 norepinefrina mayor de 0.1 μg/kg/min/BalT mayor de 3,805 ml. Se evaluó el desarrollo de complicaciones Post-THO. Las variables principales de valoración fueron; complicaciones médicas generales, reoperación quirúrgica y duración de estancia en el hospital (DEH), duración de la ventilación mecánica, lesión renal aguda, función anormal del injerto y cultivos positivos. Resultados: 36.6% de los pacientes pertenecían al grupo 1, 18.8% al grupo 2, 17.8% al grupo 3 y 26.7% al grupo 4. La duración de la estancia fue de 3.39 días, tiempo medio de ventilación mecánica de 16.5 horas. El 67% desarrolló complicaciones médicas, el 15.8% de reoperación quirúrgica, el 62% de lesión renal aguda, el 50.5% de función anormal del injerto y el 45.5% de cultivos perioperatorios positivos. La duración de la estancia fue de 3.39 días, tiempo medio de ventilación mecánica de 16.5 horas. De estos criterios de valoración primarios, sólo la duración de la estancia y la duración de la ventilación mecánica fueron diferentes entre los grupos. Conclusiones: La duración de la estancia y la necesidad de ventilación mecánica, fueron diferentes entre los grupos. El desarrollo de otros criterios de valoración primarios fue independiente del modelo de resucitación.

Abstract: The resuscitation period after orthotopic liver transplantation (OLT) is challenging due to the physiological alterations related to end stage liver disease (ESLD). Material and methods: This is a retrospective study assessing the first 48 hours management at the intensive care unit (ICU) of at hospital in México City. Patients were categorized into 4 groups according to norepinephrine (NADR) dose used and net fluid balance (BalT): group 1 norepinephrine < 0.1 μg/1 kg/min/BalT 3,805 mL, group 2 norepinephrine > 0.1 μg/kg/min/BalT < 3,805 mL, group 3 norepinephrine < 0.1 μg/kg/min/BalT > 3,805 mL, group 4 norepinephrine > 0.1 μg/kg/min/BalT > 3,805 mL. The relationship with the development of Po-OLT complications was assessed. Primary endpoints were general medical complications, surgical reoperation, and length of stay (LOS), length of mechanical ventilation, acute kidney injury, abnormal graft function and positive cultures. Results: 36.6% of the patients belonged to group 1, 18.8% to group 2, 17.8% to group 3, and 26.7% to group 4. The length of stay was 3.39 days, mean time of mechanical ventilation of 16.5 hours. 67% developed medical complications, 15.8% surgical reoperation, 62% acute kidney injury, 50.5% abnormal graft function and 45.5% positive perioperative cultures. Of these primary endpoints, only length of stay and length of mechanical ventilation were different among groups. Conclusions: Length of stay and mechanical ventilation need was different among groups. Development of other primary endpoints was independent of the resuscitation model.

Resumo: O período de reanimação no pós-operatório de transplante hepático ortotópico (THO) é um desafio devido a alterações fisiológicas relacionados com a doença hepática terminal (DHT). Material e métodos: Realizou-se um estudo retrospectivo que avaliou as primeiras 48 horas do THO na unidade de terapia intensiva (UTI) de um hospital na Cidade do México. Os pacientes foram classificados em 4 grupos de acordo com a dose de norepinefrina (NADR) utilizada e o balaço hidrico (BalT): grupo 1 norepinefrina menor de 0.1 μg/1 kg/min/BalT menor de 3.805 ml, grupo 2 norepinefrina maior de 0.1 μg/kg/min/BalT menor de 3.805 ml, grupo 3 norepinefrina menor de 0.1 μg/kg/min/BalT maior de 3.805 ml, grupo 4 norepinefrina maior de 0.1 μg/kg /min/BalT maior de 3.805 ml. Analizou-se a relação que existe com o desenvolvimento de complicações Post-THO. As principais variáveis da avaliação foram: complicações médicas, reintervenção cirúrgica e tempo de permanência hospitalária, duração da ventilação mecânica, lesão renal aguda, função anormal do enxerto e cultivos positivos. Resultados: 36.6% dos pacientes pertenciam ao grupo 1, 18.8% ao grupo 2, 17.8% para o grupo 3 e 26.7% ao grupo 4. O tempo de permanência hospitalar foi 3.39 dias, ventilação mecânica de 16.5 horas tempo médio. 67% desenvolveram complicações médicas, 15.8% reintervenção cirúrgica, 62% de lesão renal aguda, 50.5% função anormal do enxerto e 45.5% de cultivos pré-operatórios positivos. Destes parâmetros, o TEUTI e TVM apresentaram diferenças entre os modelos de reanimação. Conclusão: O TEUTI e TVM variaram de acordo ao modelo de reanimação. Os outros resultados primários foram independentes ao modelo de reanimação.

[The process of death in the intensive care unit (ICU). From a medical, thanatological and legislative point of view]. / El proceso de muerte en la unidad de cuidados intensivos (UCI). Punto de vista médico, tanatológico y legislativo.

Traditional goals in the intensive care unit are to reduce morbidity and mortality. Despite medical and technological advances, death in the intensive care unit remains commonplace and the modern critical care team should be familiar with palliative care and legislation in Mexico. Preserving the dignity of patients, avoiding harm, and maintaining communication with the relatives is fundamental. There is no unique, universally accepted technical approach in the management of the terminal critical care patient, so it is important to individualize each case and define objectives together under the legal framework in Mexico.

Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery.

BACKGROUND: The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. METHODS: Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. RESULTS: There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. CONCLUSIONS: In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.

Hipertensión arterial pulmonar por ecocardiografía en pacientes con enfermedades de tejido conectivo / Pulmonary hypertension associated with connective tissue diseases

Background: Pulmonary arterial hypertension is an important cause ofcomplica-tions amongpatients with connective tissue diseases. Aim: To describe the clinical and echocardiographic characteristics ofpatients with pulmonary hypertension associated with connective tissue diseases. Material and Methods: Retrospective, observational and descriptive study. We analyzed 35 patients with pulmonary hypertension associated with connective tissue diseases. All patients were evaluated and diagnosed by at least one medical specialist in rheumatology. Pulmonary arterial hypertension was defined as a pulmonary artery systolic pressure ≥ 40 mmHg by echocardiography. The group was divided as not severe when pressures ranged from 40 to 64 mmHg and severe, when pressures were ≥ 65 mmHg. Results: The most common connective tissue disease associated with pulmonary arterial hypertension was diffuse scleroderma in 46% of cases. Eighty nine percent of patients were female. Time of evolution of the pulmonary hypertension was 18.8 ± 21.8 months. The distance walked in the six minute walk test was < 400 m both in patients with and without severe pulmonary hypertension. Fifty one percent ofpatients had pulmonary restriction. No differences in gas exchange parameters were observed between groups. Comparing echocardio-graphic findings in patients with and without severe hypertension, the former had a higher frequency ofright ventricular dilatation (85.7 and 52.3% respectively, p = 0.04), right ventricular hypertrophy (42.8 and 0% respectively, p = 0.02) and right ventricular hypokinesia (71.4 and 9.5% respectively p = < 0.01). Conclusions: Patients with severe pulmonary arterial hypertension associated to connective tissue diseases have more commonly dilated, hypertrophic and hypokinetic right ventricles.

Impact of surgically-induced weight loss on respiratory function: a prospective analysis.

BACKGROUND: Morbid obesity (MO) causes several degrees of respiratory impairment that may resolve after weight reduction. The aims of the present study were to investigate the frequency of respiratory impairment in a selected cohort of morbidly obese patients with BMI 40-50 kg/m(2) with no respiratory symptoms and to evaluate the impact of surgically-induced weight loss on respiratory function. METHODS: Prospective analysis of respiratory impairment was conducted before surgery and 1 year after surgery in a cohort of patients with MO who underwent vertical banded gastroplasty (VBG). 30 consecutive patients with MO who underwent VBG (14 open and 16 laparoscopic) in a 1-year period were studied. Respiratory function tests, arterial blood gases and hemoglobin were obtained in all patients before and 1 year after VBG. RESULTS: Results were analyzed using the Wilcoxon signed-rank test and Spearman for variables without normal distribution. Mean age was 35+/-8 years; there were 3 males and 27 females. BMI was 44+/-4 kg/m(2) before surgery and 32+/-4 kg/m(2) at 1-year follow-up. By respiratory function tests, the diagnosis of obstructive disease was made before surgery in 4 patients and a restrictive disorder was identified in 4 additional patients. Evidence of pulmonary disease was absent in all patients 1 year after surgery. Forced vital capacity, inspiratory and expiratory forces, tidal volume, SaO(2), and PaCO(2) significantly improved after weight reduction. CONCLUSION: Surgically-induced weight loss significantly improves pulmonary function.

[A predictive model of mortality in the ICU of a Mexico City hospital]. / Un modelo predictivo de mortalidad en una UCI de un hospital de la ciudad de México.

OBJECTIVE: To explore the associations of mortality with routine logbook information as a preliminary to developing a quality control system in an ICU. METHODS: The ICU logbook contained seven variables of 2,745 consecutive cases hospitalized from Jan-01-1998 to Dec-31-2002. The univariate association of ICU mortality with five predictive and two non-predictive variables was explored. Gender was the only one unassociated. A logistic regression predictive model of mortality of three variables was generated (cause of hospitalization, age and type of patient). RESULTS: The global mortality was 27%. The highest risk was for non-surgery patients aged 80+ years with multiple organic failure, sepsis and/or pneumonia. They had a relative risk of 18.1 versus the reference group (surgical cases aged 20-39 with less severe illnesses). Three additional simple predictors were identified as potentially useful and are to be included in an updated logbook. CONCLUSIONS: 1. The logbook information appeared to be useful in monitoring ICU quality of service as six logbook variables were associated to mortality. 2. Our predictive model has the potential to operate as an index of severity of disease and may improve by the inclusion of additional information. 3. Its usefulness is to be compared prospectively with well-established predictors (Apache II and others).

Pressure-induced rhabdomyolysis after bariatric surgery.

Rhabdomyolisis most commonly occurs after muscle injury, alcohol ingestion, drug intake and exhaustive exercise. Prolonged muscle compression at the time of surgery may produce this complication. Obesity has been reported as a risk factor for pressure-induced rhabdomyolysis, but no reports associated with bariatric surgery could be found in the literature. We report 3 superobese patients who developed rhabdomyolysis after bariatric surgery. This complication was attributed to direct and prolonged pressure of the bed against the dorsal and gluteal muscles.

Open versus laparoscopic vertical banded gastroplasty: a randomized controlled double blind trial.

BACKGROUND: Vertical banded gastroplasty (VBG) is a frequently used surgical procedure for the treatment of morbid obesity. It can be done open (OVBG) or laparoscopic (LVBG). The aim of this double-blind randomized clinical trial was to compare the postoperative outcome and 1-year follow-up of 2 cohorts of patients who underwent either OVBG or LVBG. PATIENTS AND METHODS: 30 patients with morbid obesity were randomized into 2 groups (14 OVBG and 16 LVBG). Pain intensity, analgesic requirements, respiratory function, and physical activity were blindly analyzed during the first 3 postoperative days. Complications, weight loss, and cosmetic results after 1 year follow-up were evaluated. RESULTS: Both groups were highly comparable before surgery. Surgical time was longer in the laparoscopic procedure. Patients in this group required less analgesics during the first postoperative day. There was an earlier recovery in the expiratory and inspiratory forces, as well as faster recovery of physical activities in patients who underwent LVBG. Postoperative complications were more frequent in the open group. Excess body weight loss after 1 year was similar in both groups. Cosmetic results were significantly better in the laparoscopic group. CONCLUSIONS: LVBG had advantages over the open procedure in terms of analgesic requirements, respiratory function, postoperative recovery, and cosmetic results.

Efectos de los cambios de posición sobre la oxigenación, cortos circuitos y hemodinamia sistémica en pacientes con síndrome de insuficienia respiratoria progresiva aguda. Presentación de dos casos clínicos / Effects of the position changes on oxygenation, intrapulmonary shunt and systemic hemodynamia in patients with acute respiratory distress syndrome. report of two cases

Introducción. El decúbito prono se ha empleado en el tratamiento del síndrome de insuficiencia respiratoria aguda (SIRPA). Objetivo. Reportar los efectos del decúbito prono en dos enfermos con SIRPA. Reporte de los casos. Dos pacientes del sexo femenino ingresaron a una unidad de cuidados intensivos (UCI) después de que presentaron súbitamente insuficiencia respiratoria. Se observó hipoxemia refractaria, disminución de la distensibilidad e infiltrados pulmonares bilaterales pocas horas después. Debido a que con la ventilación mecaníca convencional no se observó mejoría, se cambió a las pacientes a decúbito prono. En las siguientes horas se observó una mejoría notable de los parámetros respiratorios y se pudo descontinuar la ventilación mecánica pocos días después. Conclusión. El decúbito supino puede mejorar la oxigenación en los pacientes con SIRPA