Neumonía en el paciente crítico: diagnóstico sindrómico rápido de PCR múltiple en un hospital general de agudos / Pneumonia in the critically ill patient: rapid syndromic diagnosis by multiplex PCR in a general hospital for acute care

Está demostrado en diversos estudios que los avances en el diagnóstico microbiológico reducen el tiempo de entrega de resultados y poseen un impacto clínico eviden-te. Hoy en día, las técnicas basadas en amplificación de ácidos nucleicos nos permiten hacer diagnóstico direc-tamente de la muestra y sumar la posibilidad de detectar más de un agente. Esto impacta tanto en el control de la multiresistencia (MR) como en el inicio de una terapéuti-ca apropiada. La implementación de un sistema de PCR múltiple rápido para neumonía puede ser útil en áreas crí-ticas, donde son frecuentes las infecciones respiratorias agudas (IRA) y el tiempo es un condicionante del éxito terapéutico. El objetivo de nuestro proyecto fue evaluar la implementación del diagnóstico sindrómico rápido por PCR múltiple para neumonía en el manejo del tratamiento de IRA en una unidad de cuidados intensivos. La con-ducta terapéutica fue la variable relevante. Este nuevo diagnóstico nos proporcionó una herramienta ágil, con un tiempo de respuesta de tres a cuatro horas. La ausencia o presencia de genes de resistencia y el microorganismo identificado fueron lo que condujo a la conducta terapéuti-ca acertada en el 75% de los casos. Constituyó una herra-mienta importante para el control de la multirresistencia bacteriana y aumentó la oportunidad de éxito terapéutico

It has been shown in various studies that advances in microbiological diagnosis reduce the delivery time of results and have an evident clinical impact. Today, techniques based on nucleic acid amplification allow us to diagnose directly from the sample and add the possibility of detecting more than one agent. This impacts both the control of MR and the initiation of appropriate therapy. The implementation of a rapid multiplex PCR system for pneumonia can be useful in critical areas where acute respiratory infections (ARI) are frequent and time is a determining factor for therapeutic success. The objective of our project was to evaluate the implementation of rapid syndromic diagnosis by multiple PCR for pneumonia in the management of ARI treatment in an Intensive Care Unit. The therapeutic behavior was the relevant variable. This new diagnosis provided us with an agile tool, with a response time of 3 to 4 hours. The absence or presence of resistance genes and the identified microorganism was what led to the correct therapeutic approach in 75% of the cases. It constituted an important tool for the control of bacterial multiresistance and increased the opportunity for therapeutic success.

Arsenicum albumas a treatment for pneumonia in snakes: three serial cases

two Python bivittatussnakes were received at Project Selva Viva, a zoo in Taubaté, Brazil, both presenting respiratory noises and oro-nasal discharge. A thoracic ultrasonographic examination was performed for evaluation on February 25th,2022, which diagnosed the presence of multiple vertical hyperechoic artifactsemerging from the pleural line, coalescing in some of the examined areas, and the presence a hypoechoic structure located in the subpleural region. Another serpent, from the Boa constrictor species, was apprehended and arrived at the same zoo without medical history, showing a low body score. During a thoracic ultrasonographic evaluation realized on April 1st,2022, B lines emerging from the pleural line were found. These vertical reverberating lines are a result of respiratory illness (SOLDATI et al., 2014).Methodology:The report was authorized by the owner of the zoo. All the patients received homeopathic therapy with 2 globules of Arsenicum album30 cH/ BID into the mouth, after being diagnosed with the respiratory condition by the ultrasonographic examination. The medication was chosen according to the similarity with the symptoms. The snakes had a runny nose and hissing breathing noise. Weekly ultrasound scans were performed on the Python bivittatus snakes to follow up on the respiratory condition. Results: On March 04th, it was observed that both snakes showed a reduction in respiratory noises and were more active. Ars 30 cH was maintained BID. On March 25th, both presented significant improvement in the ultrasound images, which showed only A lines, compatible with a healthy lung, and the treatment was suspended. Boa constrictor snake ́streatment started on April 1st. On April 8th, the ultrasonographic examination performed only presented A lines, which are characterized in ultrasound by parallel horizontal lines in the near field with the loss of image continuity in the far field, indicating improvement of the condition (LICHTENSTEIN et al., 2003). Conclusion:Given these results, the homeopathic treatment is an option to be considered for the treatment of respiratory symptoms in snakes, although the duration of the therapy varies based on the stage and chronicity of the disease.

The effect of single-dose and continuous skeletal muscle paralysis on respiratory system compliance in paediatric intensive care patients.

OBJECTIVE: To investigate the effect of single dose and continuous skeletal muscle paralysis on respiratory system compliance in 53 paediatric intensive care patients. DESIGN: Prospective clinical study. SETTING: Multidisciplinary paediatric intensive care unit. PATIENTS: Twenty-three children ventilated for acute pulmonary pathology, and 30 ventilated for isolated intracranial pathology, who initially had normal lungs. INTERVENTIONS: The 23 patients with acute pulmonary pathology received a single dose of muscle relaxant to facilitate diagnostic procedures. Fifteen patients with isolated intracranial pathology received continuous skeletal muscle paralysis for longer than 24 h, and the other 15 received no paralysis. MEASUREMENTS AND RESULTS: Respiratory system compliance deteriorated by 14% from 0.519 +/- 0.2 to 0.445 +/- 0.18 ml cmH2O-1 kg-1 (p < 0.001) following a single dose of muscle relaxant in the 23 patients with acute pulmonary pathology. In the 15 with isolated intracranial pathology who received continuous skeletal muscle paralysis there was a progressive deterioration in compliance, which reached 50% of the initial compliance by day 4 of paralysis (p < 0.001) and improved back to normal following discontinuation of paralysis. There were no changes in compliance in the 15 patients with isolated intracranial pathology who were ventilated but not paralysed. The paralysed patients required mechanical ventilation longer than the non-paralysed patients (p < 0.001), and 26% of these patients developed nosocomial pneumonia (p = 0.03), a complication that was not seen in the non-paralysed patients. CONCLUSIONS: Skeletal muscle paralysis results in immediate and progressive deterioration of respiratory system compliance and increased incidence of nosocomial pneumonia. The benefits of paralysis should be balanced against the risks of deteriorating pulmonary function.

[Prolonged neuromuscular damage following corticosteroids and muscle relaxants].

Many patients mechanically ventilated for acute respiratory failure, are treated with medication that includes a combination of cortico-steroids and non-depolarizing neuromuscular-blocking agents (NNBa). A third of them can be expected to develop delayed neuromuscular damage, which may be severe and prolonged. We describe a 50-year-old man who suffered from acute myeloid leukemia and was ventilated due to pneumonia. He was treated with pancuronium and cortico-steroids, and during recovery suffered quadriparesis that lasted several months. Typically this damage is purely motor and is accompanied by absent tendon-reflexes, sometimes with elevated creatine-kinase. Muscle biopsy usually shows deletion and degeneration of thick myosin filaments. The phenomenon is related to the duration of NNBa treatment, and probably results from an adverse synergistic effect on muscle tissue of the cortico-steroids and cortico-steroid-like NNBa given the immobilized patient. Awareness of this adverse effect of steroids and pancuronium, the use of passive mobilization, shortening the use of NNBa and early rehabilitation would minimize disability due to this phenomenon.

Homeopatia no tratamento de pneumonia com derrame pleural na UTI pediátrica: relato de caso / Homeopathy in the treatment of pneumonia with pleural effusion in the pediatric ICU: a case report

O presente artigo relata um caso de tratamento de pneumonia associada com derrame pleural, em um pré-escolar de 4 anos de idade, com antecedentes de alergia alimentar, refluxo gastresofágico, rinite, asma, hipogamaglobulinemia, eosinofilia, gastrite, encefalite e internações prévias por pneumonia. Além do comprometimento pulmonar, apresentava alteração do sistema nervoso central, com alternância de sonolência e agitação psicomotora. Foi tratado com Bryonia alba 30 cH 1 gota dose única, tendo boa evolução clínica e após 4 dias do inicio do tratamento homeopático, teve alta do UTI Pediátrica.(AU)

This article reports the homeopathic treatment of pneumonia with pleural effusion in a 4-year-old boy with a background of food allergy, gastroesophageal reflux, rhinitis, asthma, hypogammaglobulinemia, eosinophilia, gastritis, encephalitis and previous hospitalizations due to pneumonia. Besides the affection of the lungs he exhibited disturbs of the central nervous system, with sleepiness alternating with psychomotor agitation. He was treated with Bryonia alba 30cH 1 drop single dose, exhibiting good clinical response and 4 days after the onset of homeopathic treatment could be discharged from the pediatric ICU.(AU)

Homeopatia no tratamento de pneumonia com derrame pleural na UTI pediátrica: relato de caso / Homeopathy in the treatment of pneumonia with pleural effusion in the pediatric ICU: a case report

O presente artigo relata um caso de tratamento de pneumonia associada com derrame pleural, em um pré-escolar de 4 anos de idade, com antecedentes de alergia alimentar, refluxo gastresofágico, rinite, asma, hipogamaglobulinemia, eosinofilia, gastrite, encefalite e internações prévias por pneumonia. Além do comprometimento pulmonar, apresentava alteração do sistema nervoso central, com alternância de sonolência e agitação psicomotora. Foi tratado com Bryonia alba 30 cH 1 gota dose única, tendo boa evolução clínica e após 4 dias do inicio do tratamento homeopático, teve alta do UTI Pediátrica.

This article reports the homeopathic treatment of pneumonia with pleural effusion in a 4-year-old boy with a background of food allergy, gastroesophageal reflux, rhinitis, asthma, hypogammaglobulinemia, eosinophilia, gastritis, encephalitis and previous hospitalizations due to pneumonia. Besides the affection of the lungs he exhibited disturbs of the central nervous system, with sleepiness alternating with psychomotor agitation. He was treated with Bryonia alba 30cH 1 drop single dose, exhibiting good clinical response and 4 days after the onset of homeopathic treatment could be discharged from the pediatric ICU.

Acute cardiopulmonary effects of pancuronium bromide in mechanically ventilated newborn infants.

The short-term effects of muscle relaxation with pancuronium bromide on arterial blood gas values, heart rate, and arterial blood pressure were studied in 49 neonates receiving mechanical ventilation. After pancuronium administration, mean PaO2 increased from 61.9 +/- 30.0 to 80.9 +/- 52.8 mm Hg (P = 0.006), mean PaCO2 decreased from 40.1 +/- 13.0 to 37.5 +/- 13.3 mm Hg (P = 0.03), and mean heart rate rose from 146.2 +/- 24.9 to 161.0 +/- 20.5 beats/min (P less than 0.001). Arterial blood pressure did not change significantly. When results were analyzed by diagnosis (meconium aspiration syndrome, hyaline membrane disease, pneumonia), only infants with meconium aspiration syndrome had a significant improvement in oxygenation (P = 0.008). Six of 18 patients with hyaline membrane disease responded to muscle relaxation, with a decrease in PaO2 of 10 mm Hg or more. No significant correlation was found between change in PaO2 and birth weight, gestational age, postnatal age, or change in heart rate. A weak correlation (r = -0.37, P less than 0.006) was observed between change in PaO2 and change in PaCO2. Although the reasons for the divergence in response in different groups of patients are not entirely clear, the risk of deterioration with pancuronium therapy should be kept in mind, particularly if treatment in an infant with hyaline membrane disease is being considered.

Whose child is it anyway? Resolving parent-physician conflict in the NICU setting.

Much has been written on parental involvement in decision making when dealing with critically ill children, but few articles have touched upon parental refusal of treatment in noncritically ill children. What steps should be taken when a parent refuses what is generally considered "standard of care" medicine for their hospitalized child? Does medical advice outweigh parental views or wishes, and what does one do when our role as physician turns from medical expert into one of medical negotiator? The following case and discussion deal with parental refusal of conventional medical care, and how one may find peaceful resolutions to challenging situations for the ultimate good of the child.

Anaesthetic practice and postoperative pulmonary complications.

The aim of this study was to identify risk factors associated with postoperative pulmonary complications. The influence of the anaesthetic technique was evaluated (i.e. general contra regional anaesthesia and long contra intermediately acting muscle relaxants (pancuronium and atracurium)) taking into account the patient's age, the presence or absence of chronic obstructive lung disease (preoperative risk factors), the type of surgery and the duration of anaesthesia (perioperative risk factors). Seven thousand and twenty-nine patients undergoing abdominal, urological, gynaecological or orthopaedic surgery were included in the study. A total of 290 patients (4.1%) suffered from one or more postoperative pulmonary complications. Six thousand and sixty-two patients received general anaesthesia and 4.5% of these had postoperative pulmonary complications. Of the patients admitted to major surgery receiving pancuronium, 12.7% (135/1062) developed postoperative pulmonary complications, compared to only 5.1% (23/449) receiving atracurium (P < 0.05). When stratified for type of surgery and duration of anaesthesia, conventional statistics showed no difference between pancuronium and atracurium as regard postoperative pulmonary complications. However, a logistic regression analysis indicated that long-lasting procedures involving pancuronium entailed a higher risk of postoperative pulmonary complications than did other procedures. In patients having regional anaesthesia, only 1.9% (18/967) developed postoperative pulmonary complications (P < 0.05 compared to general anaesthesia). However, when stratified for type of surgery there was a significantly higher incidence of postoperative pulmonary complications only in patients undergoing major orthopaedic surgery under general anaesthesia, 11.5% compared to 3.6% in patients given a regional anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Estudio retrospectivo multicéntrico sobre la efectividad de la homeopatía en pacientes con neumonía / Multicenter retrospective study on the effectiveness of homeopathy in patients with pneumonia

El estudio está basado en 39 casos de pacientes diagnosticados con neumonía y tratados según el método establecido por Samuel Hahnemann en el Organon. Observa los medicamentos más frecuentemente indicados, teniendo en cuenta la repertorización individual de los síntomas de cada paciente en el cuadro agudo. Hace un estudio comparativo sobre la evolución de los pacientes en función de las potencias utilizadas (30CH y 6LM) y de la conveniencia, o no, de la continuidad del tratamiento hasta la ausencia total de los síntomas clínicos. (AU)

This study is grounded on 39 cases of patients with pneumonia, who have been treated according to the method established by Samuel Hahnemann in the Organon. I pointed to the most frequently indicated remedies to treat this condition, following the individual repertorization of the symptoms of each patient. I compared also the evolution of the cases depending of the use of 30CH or 6LM potencies. I also questioned the suitability of continuing the treatment once the clinical symptoms have vanished. (AU)

Estudio retrospectivo multicéntrico sobre la efectividad de la homeopatía en pacientes con neumonía / Multicenter retrospective study on the effectiveness of homeopathy in patients with pneumonia

El estudio está basado en 39 casos de pacientes diagnosticados con neumonía y tratados según el método establecido por Samuel Hahnemann en el Organon. Observa los medicamentos más frecuentemente indicados, teniendo en cuenta la repertorización individual de los síntomas de cada paciente en el cuadro agudo. Hace un estudio comparativo sobre la evolución de los pacientes en función de las potencias utilizadas (30CH y 6LM) y de la conveniencia, o no, de la continuidad del tratamiento hasta la ausencia total de los síntomas clínicos.

This study is grounded on 39 cases of patients with pneumonia, who have been treated according to the method established by Samuel Hahnemann in the Organon. I pointed to the most frequently indicated remedies to treat this condition, following the individual repertorization of the symptoms of each patient. I compared also the evolution of the cases depending of the use of 30CH or 6LM potencies. I also questioned the suitability of continuing the treatment once the clinical symptoms have vanished.

Estudo de crianças com síndrome do desconforto respiratório agudo: correlaçäo anatomoclínica radiológica / A study of children with acute respiratory distress syndrome: histopathological, clincal and radiological correlation

Estudo retrospectivo com revisäo dos casos clínicos de Sídrome do Desconforto Respiratório Agudo, realizado no período de out/88 a dez/90 na Unidade de Pacientes Graves do Instituto Fernandes Figueira. Os autores estudaram as características clínicas, radiológicas e histopatológicas de acordo com o estágio evolutivo da doença. Dentre 459 casos estudados, foram selecionados 49 (11 por cento). Onze casos tiveram exame anatomopatológico [biopsia (4), necropsia (8) e foram classificados de acordo com o estágio evolutivo em: fase exsudativa inicial, fase proliferativa celular e fase proliferativa fibrótica. Houve correlaçäo clínica radiológica e anatomopatológica nos casos confirmados com exame histológico. Os autores consideram importante estudos futuros em que a interaçäo entre a pesquisa clínica e experimental permita o melhor conhecimento desta Síndrome na populaçäo pediátrica

Limitacoes da homeopatia: enfoques terapeuticos / Homeopathy limitations: therapeutical aspects

The paper's objetive is to stimulate exploration of therapeutic resurses within homeopathie suggesting clinical application of different levels of similitude: Constitutional, Anathomopathologic and ethiopathogenic; through clinical studies in sixteen pacients suffering inespecifc acute pulmonary infections and treated with Antimonium ars. 6 CH and Pyrogenium 200

Pneumonia with a paucity of symptoms

A case of pneumonitis with few symptoms is presented. After Sulphur in high potency produced an incomplete response, Antimonium tartaricum was prescribed with curative results. The principle indicators of the latter remedy were: intermittent respirations, somnolence, rattling cough with difficult expectoration, thirstlessness