[Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Report of two cases]. / Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media.

Malignant middle cerebral territory infarction represents 5 to 10% of all brain infarctions. Its mortality is 80%, due to brain herniation and it is not reduced by medical treatment. Decompressive hemicraniectomy reduces mortality to 12%, and the subsequent quality of life of patients is acceptable. We report two male patients aged 61 and 54 years, with a malignant middle cerebral territory infarction who were treated with decompressive hemicraniectomy. After two years of follow up, both patients are self-sufficient and live at home with their families.

Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: Primer estudio nacional multicéntrico / Prevalence of severe sepsis in Intensive Care Units: A national multicentric study

Background: Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). Aim: To study the prevalence of SS in Chilean ICUs. Material and methods: An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Results: Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66 percent. Mean age of patients was 57.7+18 years and 59 percent were male, APACHE II score was 15+7.5 and SOFA score was 6+4. SS was the admission diagnosis of 94 of the 283 patients (33 percent) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40 percent). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9 percent (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7 percent (30/112) and 8.7 percent (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48 percent respiratory and 30 percent abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. Conclusions: SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APA CHE II and SOFA scores were independent predictors of mortality.

Hemicraniectomía descompresiva en dos pacientes con infarto maligno de la arteria cerebral media / Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Report of two cases

Malignant middle cerebral territory infarction represents 5 to 10 percent of all brain infarctions. Its mortality is 80 percent, due to brain herniation and it is not reduced by medical treatment. Decompressive hemicraniectomy reduces mortality to 12 percent, and the subsequent quality of life of patients is acceptable. We report two male patients aged 61 and 54 years, with a malignant middle cerebral territory infarction who were treated with decompressive hemicraniectomy. After two years of follow up, both patients are self-sufficient and live at home with their families.

Determinación y análisis comparativo de gasto cardíaco en enfermos críticos mediante Doppler transesofágico y termodilución en bolos: Experiencia preliminar / Comparison of cardiac output measurement in critical patients using transesophageal Doppler or thermodilution: A preliminary report

Background: Cardiac output can be measured non invasively by transesophageal Doppler. This is an alternative to measure it by thermodilution with a catheter in the pulmonary artery. Aim: To compare both methods of cardiac output measurement. Material and methods: Simultaneous measurement of cardiac output by transesophageal Doppler and thermodilution with a catheter in the pulmonary artery in four male critical patients, aged 60±12 years, hospitalized in a University Hospital. The Bland and Altman method to compare the concordance between two measurements, was used. Results: Forty measurements were performed. The results of both methods had a correlation coefficient of 0.98. According to the Bland and Altman method, the difference between both methods was -0.5 L with a precision of 0.52 L/min (95% confidence interval -1.51 to 0.52 L/min). Considering that a change between two sequential measurements is considered significant when the difference is more than 15%, both measurements agreed in 83% of cases, that there was a change in cardiac output. Conclusions:Transesophageal Doppler is a promising non invasive technique to measure cardiac output in critical care patients. It becomes a valid alternative to the thermodilution technique. This preliminary experience must be confirmed in a larger series.

Necrólisis epidérmica tóxica: terapia en UCI con inmunoglobulinas intravenosas en un caso / Toxic epidermal necrolysis: report of 1 case treated with intravenous immunoglobulins

We report a 27 years old homosexual male with AIDS that was admitted to the ICU dehydrated, with fever and severe malaise. He had irregular bullae, an extensive purpuric exanthema and a zone of epidermic detachment in the right arm. A toxic epidermal necrolysis was diagnosed and therapy with i.v. immunoglobulins was started. After four days of treatment, bullous lesions disappeared and the extension of exanthema decreased. Toxic epidermal necrolysis is a potentially fatal disease and the use of intravenous immunoglobulins for this condition has been reported as successful

Vibrio vulnificus: una causa infrecuente de shock séptico / Septic shock caused by vibrio vulnificus: report of 1 case

Vibrio vulnificus is a lactose positive Gram negative rod that lives in warm seas and can infect wounds and produce sepsis. Its infection is acquired after eating oysters or other filtering marine organisms. We report a 53 years old diabetic male who started with fever after a voyage to Central America. He was admitted febrile, hipotense, dehydrated and polypneic. Painful erythematous lesions and lumps were observed in his upper and lower limbs. After 72 hours of evolution, the lesions became violaceous, with crepitating vesicles full of hemorrhagic exudate. He developed a renal failure and a disseminated intravascular coagulation. Blood cultures demonstrated the presence of Vibrio vulnificus and the patient died 68 hours after admission

Síndrome de respuesta inflamatoria sistémica severa: ¿es comparable a la sepsis severa? / Systemic inflammatory response syndrome: is it similar to severe sepsis?

Background: in 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions. Aim: to evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS. Patients and methods: five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient. Results: One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48 percent in sepsis compared to 43 and 51 percent in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group. Conclusions: The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies

Responsabilidad médica en la atención de pacientes en unidades de cuidados intensivos / Medical liability in the treatment of intensive care unit patients

Critical care medicine was practiced informally during several years, specially during was periods. Nowadays it is, however, a fundamental part of health systems in which patients attain care facilities of increasing complexity in a cost effective manner, according to their needs. The importance of this discipline in Chile, durign its 30 years of developments, has progressively increased and at the present time, intensive care units represent up to 30 percent of the total number of beds in some hospitals. Even though these units requiere great budgets and many resources, teheir place and the role of physicians who work in them has not been recognized adquately by the national medical community. The present document presents the official position of the Chilean Society of Intensive Medicine on the general objectives of this discipline. It indicates the scope of action of the specialty and the role of intensive care physicians, their relationship with other specialties, their duties and responsibilities with their patients

Avances en la patogenia de la encefalopatía hepática / Advances in the pathogenesis of the hepatic encephalopathy

La encefalopatía hepática (EH) es un síndrome neuropsiquiátrico cuya patogenia no ha sido hasta ahora completamente dilucidada. Se ha propuesto varias teorías que involucran agentes como el amonio, ácidos grasos de cadena corta, metabolitos de la metionina, falsos neurotransmisores y más recientemente, el principal neurotransmisor inhibitorio del sistema nervioso central humano, el ácido gama-aminobutírico. Ninguna de estas hipótesis ha sido hasta hoy definitivamente probada y se acepta que la patogenia del síndrome es multifactorial. Sin embargo, evidencias clínicas y experimentales recientes, con un correlato electrofisiológico y proyecciones terapéuticas concretas, apoyan la participación de la neurotransmisión gabaérgica en la génesis de la HE. En la presente revisión se exponen y analizan las diferentes teorías con énfasis en la teoría gabaérgica de la EH, destacando las implicancias terapéuticas futuras derivadas de esta hipótesis como el uso de fármacos antagonistas de las benzodiazepinas en el manejo de la EH

Síndrome neuroléptico maligno: aproximación médico-psiquiátrica / Malignant neuroleptic syndrome: a clinical-psychiatric approach

We report the case of a 42 years old male, with a bipolar disorder and receiving lithium therapy, valproic acid and clonazepam. Due to an exacerbation of his underlying disease, he was admitted to a psychiatric clinic and received 50 mg of intramuscular chlorpromazine in 2 ocasions. Afterwards, the patient had an alteration of conciousness, fever reaching 39ºC and generalized muscular rigidity. Laboratory work-up showed a normal brain CT scan, a diffuse slowness in the EEG and a creatinphosphokinase that reached values of 3.040 U/l. He was transferred to an intensive care unit and treated with sodium dantrolene and bromocriptine, obtaining a good clinical response

Estudio de sobrevida de los pacientes adultos mayores en unidades de cuidado intensivo: ¿deben ingresar? / Survival of elderly patients in intensive care units: should they be admitted?

We retrospectively analyzed the mortality of 443 patients older than 65 years old, admitted to an intensive care unit between 1993 and 1994. The mortality was compared with that of 334 younger patients admitted in the same period. Severity of disease was determined using admission APACHE II score. Older patients had a higher admission APACHE score than younger subjects (18.4+- and 14.5+-8.7 respectively, p 0.01). Mortality during the intensive care unit stay was similar in older and younger patients (18.5 and 14.4 per cent, respectively). Hospital mortality was also similar (22.4 and 25.9 per cent respectively). Older patients had a higher frequency of chronic diseases and degree of functional impairment. Mortality rates for different diseases were also similar in older and younger patients. Older age was not associated with a higher mortality during intensive care unit stay. Prognosis is determined by the admission severity score and the number of concomitant chronic diseases

Síndrome de falla orgánica múltiple en el curso de la insuficiencia hepática fulminante / Multiple systems organ failures in fulminant hepatic failure

Background: in fulminant hepatic failure, different organs systems become involved and a multiple systems organic failure may ensue. Aim: to perform a retrospective analysis of patients with fulminant hepatic failure admitted to UC Hospital Intensive Care Unit. Patients and methods: the charts of 14 patients (8 male) were analyzed. Multiple systems organic failure was defined as the presence of 2 or more organic dysfunctions. The evolution and mortality of these patients was analyzed. Results: patients` ages ranged from 30 to 74 years. The etiology of hepatic failure was B hepatitis in 4, non A non B hepatitis in 5, acute fatty liver of pregnancy in 3 and use of halothane and HIN in 2. ICU stay ranged from 1 to 44 days and 2 patients survived (one with drug induced liver failure and 1 with acute fatty liver of pregnancy). Mean prothrombin time was 19 ñ 9.5 per cent , total bilirrubin as 24 ñ 8.9 mg/dl and 12 patients reached grade IV encephalopathy. Mean admission APACHE II score was 21.5 ñ 6. Twelve patients developed multiple systems organic failure, that appeared 1.5 days or was already present at ICU admission; it lasted a mean of 2.5 days and all these 12 patients died. Neurologic involvement occured in 13 patients, renal in 10, cardiovascular in 9, respiratory in 5 and hematological involvement in 1. Conclusions: multiple systems organic failure is frequent in fulminant hepatic failure and is associated with a high mortality

Pronóstico vital en insuficiencia hepática aguda grave: valor de los índices cuantitativos de evaluación / Life prognosis in severe acute hepatic failure: value of assessment quantitative index

The aim of this study was to assess the predictive value for mortality of admission and daily APACHE II score, mortality due to multiple organ failure and the organ failure score in patients with acute hepatic failure. We retrospectively studied 15 such patients admitted to an intensive care unit. Thirteen patients died (87 percent) and their admission APACHE II score was 22ñ7.5 compared to 21ñ8.5 in survovors. Daily APACHE II score, mortality due to multiple organ failure and multiple organ failure score had a 100 percent sensitivity to predict mortality and a 69.2, 76.9 and 76.9 percent specificity respectively. The predictive accuracies of multiple organ failure and multiple organ failure score were 80 percent and significantly better than the accuracy of admission APACHE II score (53 percent). We conclude that these prognostic scores can be useful in the assessment of patients with acute hepatic failure

Inhalación prolongada de óxido nítrico en el distress respiratorio agudo del adulto en un caso / Prolongued inhalation of nitric oxid in acute respiratory adult distress in 1 case

Inhalation therapy with nitric oxide has been suggested as beneficial in the adult respiratory distress syndrome, however there are few reports of its prolonged use. We report a patient with a chronic lymphocytic leukemia that developed an adult respiratory distress syndrome with severe hypoxemia, refractory to conventional therapeutic measures, during the course of a septic shock. The patient received nitric oxide (19 ppm) improving arterial oxygen saturation and allowing the reduction of FiO2 to 40 percent. The patient died 5 days later due to a multiple organ failure

Inhibición de la vía del óxido nítrico en el shock séptico refractario / Inhibition of nitric oxide way in the refractary septic shock

To assess the acute effects of methylene blue infusion, an inhibitor of nitric oxyde synthesis, on hemodynamic parameters in patients with refractory septic shock. Fourteen patients admitted to intensive care units with septic shock of diverse etiologies and unable to maintain median arterial pressures over 60 mm Hg with the use of at least 2 vasoactive drugs, were studied. All received a 1 mg/kg bolus of methylene blue. Hemodinamic parameters were measured before and 30, 60, 120 and 180 min after the bolus. Systolic and diastolic blood pressure and systemic vascular resistance increased in all patients. There were no significant changes in cardiac output, oxygen consumption or extraction. Methylene blue has an acute pressor effect in patients with septic shock

Estudio clínico epidemiológico de los pacientes ingresados a UCI según grupo etáreo / Clinical epidemiological study of patients admitted at ICU according to age

The charts of all patients admitted to an intensive care unit of a University Hospital, during 1 year, were reviewed. The diagnosis that caused the admission was considered the main disease. Severity at the moment of admission was assesses using the Apache asore. A total of 777 patients were admitted during the study period. Twenty had to be excluded due to lack of reliable data. Four hundred thirty two (57 percent) were over 65 years old. Cardiovascular diseases were the main cause of admission in young and old patients. Mortality was 14,8 percent of patients over 65 years old and 18.7 percent in younger patients. Main causes of death were cardiac arrest, cardiogenic shock, sepsis and cerebrovascular disease. No differences in causes of death were observed between young and old patients. Patients older than 65 years old admitted to intensive care units are very similar to the younger counterparts in their prognosis and causes of admission

Pacientes con síndrome de distress respiratorio agudo del adulto: efectos del óxido nítrico inhalado sobre intercambio gaseoso y la hemodinamia / Patients with acute adult respiratory distress syndrome: effects of inhalated nitric oxide on gas exchange and hemodynamics

Adult respiratory distress syndrome is highly prevalent in intensive care units and has a high mortality. Lately, nitric oxide has been used as adjuvant therapy. To study the effects of nitric oxide inhalation in patients with adult respiratory distress syndrome, 12 patients were subjected to nitric oxide inhalation at a concentration of 10 parts per million, during 30 minutes. At the end of the nitric oxide inhalation period, there was an improvement of PaO2/FIOa ratio from 89ñ32 to 111ñ43 mm Hg and 16 percent reduction of lung shunting (Qs/Qt). Nitric oxide inhalation at a concentration of 10 parts per million improved arterial oxygenation and reduced pulmonary shunting in patients with adult respiratory distress syndrome