Hipotermia intravascular inducida en el manejo de la hipertensión intracraneana en insuficiencia hepática aguda: caso clínico / Intravascular hypothermia for the management of Intracranial hypertension in acute liver failure: case report

Acute liver failure has a mortality rate in excess of 80 percent. Most deaths are attributed to brain edema with intracranial hypertension and herniation of structures, where ammonium plays a major role in its generation. We report an 18 year-old female with a fulminant hepatic failure caused by virus A infection. The patient developed a profound sopor and required mechanical ventilation. A CT scan showed the presence of brain edema and intracranial hypertension. A Raudemic® catheter was inserted to measure intracranial pressure and brain temperature. Intracranial hypertension became refractory and intravascular hypothermia was started, reducing brain temperature to 33°C. Seventy two hours later, a liver transplantation was performed. After testing graft perfusion, rewarming was started, completing 122 hours of hypothermia at 33°C. The patient was discharged in good conditions after 69 days of hospitalization.

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.

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional / Mechanical ventilation in patients with acute neurological disease: Survival and functional outcome

Background: The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign. Aim: To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation. Patients and methods: Prospective study of 77 patients (42 men, age 54±19 years, with 11±4 points of Glasgow coma scale (GCS), 61 percent with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index. Results: Thirty percent of patients died during follow up. Among surviving patients, 47 percent had a good recovery or moderate disability, and 74 percent had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis. Conclusions: Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients (Rev Méd Chile 2004; 132: 11-8).

Síndrome del "hombre en el barril": reporte de un caso y revisión de la literatura / Man-in-the-barrel syndrome: a case report and review of the literature

El síndrome del "hombre en el barril" se refiere al cuadro clínico de paresia braquial proximal bilateral, que es habitualmente secundaria a una hipotensión arterial sistémica con hipoperfusión encefálica, resultando en una isquemia de zonas limítrofes. Reportamos el caso de un hombre de 57 años, con paresia braquial proximal bilateral después de una cirugía biliar debido a una colangitis. La difusión en resonancia magnética mostró lesiones hiperintensas en la zona correspondiente al límite entre los territorios de las arterias cerebrales media y anterior derechas.

Infusión de morfina para el manejo del dolor postoperatorio en pacientes sometidos a cirugía abdominal alta / Morphine infusion for postoperative pain management in patients subjected to upper abdominal surgery

We compared the efficacy and side effects of postoperative continous infusions versus intermittent intravenous on-demand morphine, with or without the addition of clonixin. Eighty five helthy patients, aged 18 to 65 years, scheduled for elective cholecystectomy were prospectively randomized: group 1 (n=22) received morphine 2,5 mg iv on-demand; group 2 (n=22) received a clonixin 400 mg/day iv infusion; group 3 (n=19) a morphine 0,4 mg/kg/day iv infusion; and group 4 (n=22) received a clonixin 400 mg/day plus a morphine 0,4 mg/kg/day iv infusion. Groups 2, 3 and 4 also received, on-demand 2,5 mg iv bolus doses of morphine. A blind observer recorder analogue and descriptive pain scores, respiratory rates and side effects for 72 hours postoperatively. Groups with morphine infusions had less overall pain scores for the first day when compared with intermitent dosing (p<0.05); these groups also had less pain during the night (p=0.0016) and required less aditional morphine (p<0.0001). Side effects were similar and no cases of heavy sedation or respiratory depression were observed. We conclude that a morphine 0.4 mg/kg/day infusion is a safe and effective alternative to on demand dosing in helathy patients after elective cholecystectomy, achieving better analgesia without increasing side-effects. Clonixin 400 mg/day seems to add no significant benefits

Nalbufina v/s fentanyl en la inducción anestésica de colecistectomía laparoscópica: efectos adversos posoperatorios precoces / Nalbuphine v/s fentanyl in the anesthesic induction of laparoscopy cholecytectomy: early adverse effects in postoperatory

Los opiáceos usados en la anestesia pueden contribuir a la emesis posoperatoria; el uso de un agonista-antagonista puede tener varias ventajas. Objetivos: comparar el fentanyl con la nalbufina, usados en la inducción anestésica, en cuando a dolor en la inyección, sedación, hipoxemia e incidencia de naúseas y vómitos posoperatorios de colecistectomía laparoscópica. Materiales y métodos: en forma aleatoria y doble ciego estudiamos 40 adultos sometidos a colecistectomía laparoscópica. Todos se premedicaron con 7,5 mg de midazolam oral 60-90 minutos antes de la cirugía. En pabellón el Grupo I (n=20) recibió fentanyl 2 ugùkg-1 ev y el Grupo II (n=20), nalbufina 200 ugùkg-1; la inducción continuó con tiopental 5-7 mgùkg-1, vecuronio 0,1 mgùkg-1 y droperidol 20 ugùkg-1. La mantención fue con N2O/O2 al 50 por ciento e isoflurano. Se evaluó dolor con la inyección y en el posoperatorio cada 30 minutos por 2 horas, la sedación, hipoxemia (SpO2<90 por ciento por 30 segundos) y náuseas y vómitos. Estas últimas fueron evaluadas además a las 9 horas. Resultados : sólo hubo diferencias entre los grupos en la incidencia de dolor con la inyección: 0 por ciento en el Grupo I versus 20 por ciento en el Grupo II (p=0,035). Conclusión: el uso de la nalbufina se asoció a dolor durante la inyección y al igual sedación, hipoxemia y emesis posoperatoria que el fentanyl en colecistectomía laparoscópica

Efecto antiemético del Droperidol: en colecistectomías electivas por laparotomía / The antiemetic effect of doperidol: in elective cholecystectomy by laparotomy

La cirugía biliar se asocia a una alta incidencia de emesis postoperatoria, que es molesta y tiene riesgos. Creemos que el droperidol podría disminuirla. Objetivos: evaluar la utilidad del Droperidol como antimético al administrarlo profilácticamente en colecistectomías por laparotomía. Materiales y métodos. Estudiamos en forma prospectiva, aleatoria y doble ciego la incidencia de náuseas y vómitos en 102 adultos sometidos a colecistectomía electiva por laparotomía. Luego de la inducción, el grupo I recibieron morfina (n=52) recibió Droperidol 20 µgxKg ev y el grupo II (n=50) placebo. En el postoperatorio los pacientes morfina y clonixino como analgésicos y evaluamos la presencia de náuseas, vómitos, grado de sedación e intensidad del dolor a las 2,4,6,9,12 y 24 horas. Resultados: no hubo diferencias demográficas entre los grupos. A las 24 horas la incidencia de náuseas y vómitos fue 42 por ciento en el grupo I y 62 por ciento en el grupo II (p=0,0466). Los pacientes del grupo I presentaron menos dolor aunque recibieron igual cantidad de analgésicos. Conclusiones: El Droperidol es un antiemético útil en colecistectomías electivas y su uso parece potenciar la analgesia postoperatoria

Síndrome de distress respiratorio del adulto en pielonefritis aguda durante el embarazo / Respiratory distress syndrome of adult in acute pyelonephritis in pregnancy

Se comunica el caso clínico de una embarazada de 17 años con pielonefritis aguda complicada de síndrome de distress respiratorio del adulto. Se describe el cuadro clínico, manejo médico y resultados de esta infrecuente, pero grave asociación. Se revisan los anteriores 17 casos publicados en la literatura mundial con sus hallazgos clínicos, de laboratorio y resolución

Morbimortalidad perioperatoria en pacientes valvulópatas sometidos a cirugía no cardíaca / Perioperative morbimortality in patients with heart valves diseases submitted to non cardiac surgery

Estudiamos en forma retrospectiva la morbimortalidad periperatoria en 80 pacientes valvulópatas sometidos a cirugía no cardíaca entre 1988 y 1989. Once pacientes (14%) presentaron una o más complicaciones, de los cuales fallecieron cuatro (5%). Dos pacientes con falla de bomba y uno por embolia mesentérica presentaron una necrosis mesentérica posoperatoria y fallecieron. El mayor deterioro de la capacidad funcional (CF) (p = 0,052), la cirugía de urgencia (p = 0,002) y la cirugía abdominal alta (p = 0,016) se asociaron a una mayor morbilidad. No hubo diferencias de morbilidad entre los pacientes con o sin cirugía valvular previa. A mayor puntaje en las clasificaciones de ASA (p = 0,018), Goldman (p < 0,001) o Detsky (p < 0,001), se asoció una mayor morbilidad. Las clasificaciones descritas son útiles en la detección de pacientes de mayor riesgo; su uso es recomendada para optimizar las condiciones perioperatorias en los pacientes de alto riesgo y disminuir así la morbimortalidad