Clinical ultrasound in the ICU: changing a medical paradigm. / Ecografía clínica en la unidad de cuidados intensivos: cambiando un paradigma médico.

In recent decades there has been an evolution from the traditional paradigm of sporadic ultrasound performed by radiologists and cardiologists in the ICU to clinical ultrasound performed by intensivists as an extension of patient evaluation rather than as a complementary test. Such clinical ultrasound aims to diagnose and treat the patient directly. All ultrasound modalities could be interesting in the ICU, either helping in decision making or guiding procedures. Clinical ultrasound training should include all the possibilities of ultrasound, and the tutelage of other trained intensivists and other specialists with more experience should be available at all times. Training should be phased into basic, advanced and expert levels, with adjustment to the contents of the CoBaTrICE Project and the recommendations of the SEMICYUC.

[Transcranial Doppler ultrasonography usefulness in cardiac arrest resuscitation]. / Utilidad del Doppler transcraneal en la resucitación de la parada cardíaca.

An effective tissue perfusion has decisive influence on the final prognosis both during cardiopulmonary resuscitation (CPR) and after recovery of spontaneous circulation (ROSC). The transcranial Doppler ultranosography (TCD) examines the velocity and pulsatility of cerebral blood flow, making it possible to perform "beat to beat" hemodynamic analysis. During CPR, TCD peak systolic velocity reflects cerebral perfusion of the chest compressions. Beyond 2 hours after ROSC, persistence in the cerebral arteries of a hemodynamic TCD pattern (low velocities with high pulsatilities) predicts poor neurological prognosis. Early or delayed presence of a hyperemic TCD pattern (high velocities with low pulsatilities) is associated conclusively with evolution to intracranial hypertension and its appearance during the rewarming process should lead to immediate return to therapeutic hypothermia. The coincidence of hypodynamic cerebral arteries and others with normal or hyperemic TCD patterns may indicate the presence of focal hypoperfusion that could predict stroke after ROSC.

[Managing the post-cardiac arrest syndrome. Directing Committee of the National Cardiopulmonary Resuscitation Plan (PNRCP) of the Spanish Society for Intensive Medicine, Critical Care and Coronary Units (SEMICYUC)]. / Manejo del síndrome posparada cardíaca. Comité Directivo del Plan Nacional de Resuscitación Cardiopulmonary de la SEMICYUC (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias).

Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the "Post-Cardiac Arrest Syndrome" and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on "clinical judgment" might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics.

[Contribution of the patent foramen ovale to the etiopathogeny of the irritable bowel syndrome]. / Contribución del foramen oval permeable a la etiopatogenia del síndrome de intestino irritable.

A higher prevalence of cardiac right-to-left shunt through a patent foramen ovale (PFO) has been recently reported in the irritable bowel syndrome (IBS). At the same time, signs of ischemia in medullary cerebral microcirculation and the presence of excess sympathetic activity in peripheral circulation have been identified, both related with change in pain perception and autonomic dysfunction characteristic of IBS. Considering these findings together, the possible etiopathogenic role of PFO in the development of IBS can be proposed, because the paradoxical embolism characteristic of PFO could damage the cerebral and intestinal microcirculation, and that injury would be also amplified by the percentage of venous blood that shunts the pulmonary filter, producing an alteration in the metabolism of serotonin, pro-inflammatory bradykinins or neurotensin, substances with a proven etiopathogenic relationship with IBS.

[Some uncommon applications of transcranial Doppler in the intensive care unit]. / Algunas aplicaciones del Doppler transcraneal no habituales en las unidades de cuidados intensivos.

We present the case of a 64-year old woman with shock related to ischemic colitis associated with paradoxical embolism through a foramen ovale. Some utilities of transcranial Doppler ultra-sonography applied in this case that could have an usual interest in intensive and intermediate care are discussed. These include analysis of the regional distribution of cerebral blood flow, intracranial arterial continuous monitoring for detection of spontaneous microembolisms and injection of microbubbles to detect right to left shunts. The added value of using power M-mode Doppler in transcranial Doppler evaluations is highlighted.

[Early defibrillation in the community: breaking barriers to save lives]. / La desfibrilación temprana en la comunidad: romper barreras para salvar vidas.

It is considered that in Spain, every year, we have more than 24,500 out-of-hospital cardiac arrests. Around 85% of these are secondary to ventricular fibrillation, with possibility of reversion in more than 90% if defibrillation is performed in the first minute of arrhythmia. However, if we delay this defibrillation, survival possibilities disappear in a few minutes. Clinical advances in last decades have not achieved satisfactory results in the treatment of cardiac arrest as survival rates at hospital discharge do not exceed 7%. Aware of this situation, the International Scientific Societies are recommending decreasing time to defibrillation, advising, at best, a time less than five minutes between the 112-call (emergency) and adequate electric discharge. Development of automated defibrillators in Emergency Medical Systems and their use by <> of <> emergency services (police, fire fighters, etc) contribute to reach this objective. Because of this, Emergency Medical Systems are modifying their assistance strategies, to implement the early defibrillation as <>. Literature showed the effective value of automated defibrillators in the public areas but their efficiency level is less than that reached with the Emergency Services. Efficiency depends on multiple factors such as type of installation, accessibility level to emergency medical services or incidence rate of sudden cardiac arrest. Thus, their introduction should be preceded by a cost-effectiveness study. Effectiveness of automated defibrillators at home, where up to 80% of cardiac arrest are produced, has still not been evaluated. Nevertheless, in the USA, its marketing with this indication has been authorized.

[Clinical relevance of patent foramen ovale and right-to-left shunt]. / Relevancia clínica del foramen oval permeable con cortocircuito derecha-izquierda.

A frequent finding in healthy individuals, patent foramen ovale (PFO) with right-to-left shunt (RLSh), is an embrionary residue that has been linked with cryptogenic stroke and peripheral ischemia. Pulmonary hypertension and entities like decompression illness, migraine with aura or plathypnea-orthodeoxia have been found to have a higher prevalence of PFO with RLSh. Some dementias and unexplained syncopes could also have some relationship. Paradoxical embolism, thrombosis of the foramen channel or the atrial structures with subsequent embolism, transient arrhythmias, prothrombotic states and vasoactive substances passage have been proposed as physiopathologic mechanisms involved. Contrast-enhanced transesophageal echocardiography is the standard reference diagnostic procedure but contrast-enhanced transcranial Doppler is a good non-invasive alternative diagnostic tool that is highly sensitive and specific.

Helicopter emergency medical service in Spain.

No studies had been conducted about Spanish HEMS programs, so we conducted a nationwide survey by phone from January to June 1999. We identified 18 HEMS programs in 13 regions, which transported 4870 patients in 1998. The primary/interhospital missions ratio was 51.25/48.75. In 78% of responding programs, the medical crew was a physician and a nurse. Only 33% of HEMS had standard medical equipment; most lacked noninvasive blood pressure monitors, and one-third of the medical personal were correctly protected with flight helmets and flight suits. It is necessary to study the cost-effectiveness of the Spanish model of HEMS.