[Pain and fear in the ICU]. / Dolor y miedo en la UCI.

Pain and fear are still the most common memories that refer patients after ICU admission. Recently an important politician named the UCI as the branch of the hell. It is necessary to carry out profound changes in terms of direct relationships with patients and their relatives, as well as changes in environmental design and work and visit organization, to banish the vision that our society about the UCI. In a step which advocates for early mobilization of critical patients is necessary to improve analgesia and sedation strategies. The ICU is the best place for administering and monitoring analgesic drugs. The correct analgesia should not be a pending matter of the intensivist but a mandatory course.

Effect of posttraumatic donor's disseminated intravascular coagulation in intrathoracic organ donation and transplantation.

INTRODUCTION: Our aim was to evaluate the influence on yield and function of intrathoracic organs from donors after severe cranial trauma complicated by disseminated intravascular coagulation (DIC). MATERIALS AND METHODS: This retrospective observational study in a patient cohort with severe cranial trauma reading to brain death compared the number of harvested thoracic organs among individuals with versus without previous DIC. We examined exclusions for organ donation and their probable relationship to DIC. We also analyzed blood components transfused to normalize coagulation parameters. The organ recipients were followed for 1 month to detect acute graft failure. RESULTS: Among 147 organ donors, 37 were brain dead after suffering severe cranial trauma and 13 met DIC criteria upon admission. We did not observe demographic differences among donors, although there was a trend for DIC donors to be younger (32 +/- 10 vs 40 +/- 21 years old; P = .11). Twenty-eight donors (12 with DIC and 16 without) and 29 donors (13 with DIC and 16 without) met age and medical criteria for potential heart or lung donation, respectively. Donation exclusion was related to trauma instead of DIC itself. We did not find any difference among the number of cardiac and lung organs harvested from organ donors with DIC (67% and 31%, respectively) or without DIC (75% and 44%, respectively). All DIC donors had clinical bleeding and received multiple units of blood products. Organs were harvested 37 +/- 23 (13 to 80) hours after admission. All patients had normalized coagulation parameters at surgery. In the postoperative evolution, none of the cardiac or lung recipients from DIC donors met primary graft failure criteria. CONCLUSIONS: We concluded that hearts and lungs from donors with previous DIC were suitable for transplant recipients.

Cardiac donor management: another point of view.

The shortage of suitable donor hearts is an important limiting factor in heart transplantation and continues to produce discussion about adequate donor management with regard to graft quality. Recent recommendations, such as limiting the doses of catecholamines for maintenance therapy of cardiac donors, have causes up to two thirds of cardiovascular surgeons to refuse a heart graft from a donor treated with dopamine doses greater than 10 microg/kg/min although endogenous catecholamines may cardiac and pulmonary complications in organ donors, these conditions may be treated using similar agents. Perhaps it is the magnitude of the endogenous catecholamine surge that produces the pathology; thereafter, the levels, may quickly decrease to the point of catecholamine depletion at the receptor level so that exogenous administration is not deleterious and even can have beneficial effects. In the hemodynamic management of organ donors, administration of catecholamines with alpha and beta-1 effects may be needed in sufficient doses to reverse the loss of sympathetic tone at the vascular and cardiac level. Hemodynamic responses display a great individual variability; therefore, a maximal dose should not be set. Catecholamine administration increases coronary artery perfusion pressure, thus optimizing the cardiac performance. Furthermore, it is possible that immunomodulatory effects of catecholamines influence acute allograft rejection rates.

Successful bilateral lung transplantation from a methanol-poisoned donor.

The shortage of suitable organ donors is an important limiting factor that is making the evaluation of marginal donors necessary and, consequently, allowing expansion of standard donor criteria for organ removal. Lung procurement after methanol poisoning is anecdotal; in fact, there is only one published case in literature and that case showed a successful outcome. In this report, we describe a case of lung donation from a previously healthy individual who died from methanol poisoning. Both lungs were successfully implanted to a 20-year-old man who suffered from cystic fibrosis. This case report is new evidence that lung transplantation from methanol-poisoned donors may be safely performed with a good outcome.

[Control strategies for difficult sedation]. / Estrategias de control de la sedación difícil.

There is a wide intra- and inter-individual variability in sedative dose requirements in mechanically ICU patients. Patient's heterogeneity, the frequent and variable organic dysfunctions, the drug interactions and the possibility of metabolite accumulation could explain this variability. However, this fact must not justify the use of excessive doses to achieve the goals of sedation. Frequently, in the absence of a specific motive, e.g. uncontrolled pain, physicians administer progressive sedative dose increases. Probably, the absence of maximum dose recommendations has originated the case's description of severe complications, sometimes mortal, or sedative toxicity, like propofol infusion syndrome. This SEMICYUC Analgesia and Sedation Work Group recommends not administering more than 4.5 mg/kg/h of propofol or 0.25 mg/kg/h of midazolam. The need to use more than these doses should force a change in the sedative or the combined administration of both. Depending on the clinical situation or the clinical patient's evolution, the use of clonidine, haloperidol or remifentanil could be better options.

[Delusion in the critical patient]. / Delirio en el paciente crítico.

Delirium, the acute confusional syndrome, is a common although infradiagnosed problem in the critically ill patient, especially the hypoactive subtype. Risk factors for delirium are previous cognitive disturbances, some comorbidities, ambiental factors and the acute organic alterations of critical illness. Delirium is associated to an increase in short and long term mortality, prolongation of mechanical ventilation, increased Intensive Care Unit (ICU) and hospital length of stay, and cognitive impairment after hospital discharge. In the last years several tools have been developed to detect delirium in critically ill patients. The Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for ICU patients (CAM-ICU) have been validated and are useful even in patients receiving mechanical ventilation. Some interventions on specific risk factors can decrease the incidence of delirium in hospitalized patients. Treatment of delirium is based on the identification and correction of contributing factors, the introduction of support measures, and pharmacological therapy for symptomatic control. Halloperidol is the first line therapy of delirium in the critically ill patient, while experience with atypical neuroleptics and other drugs is limited, precluding to do recommendations about its use. Neuroleptic drugs can produce severe side effects and need careful dosage and monitoring. When agitation is important, can be necessary the simultaneous use of benzodiazepines or propofol, and some times, the temporal and protocolized application of physical restraints.

Amniotic membrane transplantation for conjunctival epithelization of exposed dermis-fat [corrected] graft.

We report the use of amniotic membrane over dermis-fat graft to improve conjunctival epithelization when fat is exposed. A 38-year-old male with previous history of orbital implant extrusion managed with a dermis-fat graft, presented with exposed fat secondary to dermis retraction in its central area. This caused difficulty with the conjunctival growth. Eighteen days after the amniotic membrane graft placement, a complete conjunctival reepithelization and an appropriate ocular prosthesis adaptation were achieved. Therefore, the amniotic membrane graft is a useful method to improve conjunctival growth in cases of dermis-fat grafts with fat exposure and limited conjunctiva, are present.

Disruption of the intestinal barrier and bacterial translocation in an experimental model of intestinal obstruction.

Clinical evidence and the use of experimental models in laboratory animals indicate that the intestine is a reservoir of microorganisms that can cause systemic infection in the human. The purpose of this work was to study the possible effect of intestinal obstruction (IO) on the mechanical and chemical barriers that bring protection against microorganisms crossing from the intestinal lumen towards the systemic tissues. We demonstrated that 24 hours after IO, histological and ultrastructural alterations do occur, seriously compromising the structure of the intestinal barrier in 100% of the studied animals. Likewise, it was observed that during the same period, microorganisms translocation from intestine to the peritoneal cavity and liver (100 and 80% respectively) occurred. The lungs were spared. Changes observed in the intestinal epithelium are related to a process similar to that produced by intestinal ischemia: mitochondrial destruction, with subsequent decrease of its capacity to supply energy and to preserve the equilibrium and structure of the intestinal epithelium. We propose that translocation of enteric bacteria may be the cause of the infection that brings about the death a significant group of animals at 48 hours (27%) and 72 hours (33%) post-IO.

Aturdimiento miocárdico en la muerte encefálica / Stunned myocardium in brain death

No disponible

Estrategias de control de la sedación difícil / Control strategies for difficult sedation

Existe una amplia variabilidad intra e inter-individual en los requerimientos de sedantes entre los pacientes críticos ventilados. Aspectos como la heterogeneidad de los pacientes, las frecuentes y variables alteraciones orgánicas, las interacciones entre los fármacos que reciben y los efectos sedantes de los metabolitos que se pueden acumular pueden justificar esta variabilidad. Sin embargo, esta situación no puede, ni debe, justificar el uso de dosis muy elevadas para conseguir los objetivos. Ante la agitación de los pacientes ventilados y en ausencia de una causa médica tratable (como el dolor no controlado), los clínicos responden con un incremento progresivo de la dosis de sedantes administrados. Probablemente la carencia de recomendaciones, en cuanto a la dosis máxima y el límite de los sedantes, ha conducido a la aparición de toxicidad, a veces mortal, con el uso de estos fármacos. Este grupo de trabajo recomienda no superar dosis de 4,5 mg/kg/h de propofol y 0,25 mg/kg/h de midazolam. Necesidades superiores a esta dosis máxima obligaría al cambio de sedante o a la coadministración de un segundo fármaco. Dependiendo de la situación clínica del paciente y del objetivo a corto plazo de la estrategia de sedoanalgesia, la combinación de los dos sedantes o el uso de clonidina, haloperidol o remifentanilo son las alternativas válidas (AU)

There is a wide intra- and inter-individual variability in sedative dose requirements in mechani- cally ICU patients. Patient’s heterogeneity, the frequent and variable organic dysfunctions, the drug interactions and the possibility of metabolite accumulation could explain this variability. However, this fact must not justify the use of excessive doses to achieve the goals of sedation. Frequently, in the absence of a specific motive, e.g. uncontrolled pain, physicians administer progressive sedative dose increases. Probably, the absence of maximum dose recommendations has originated the case’s description of severe complications, sometimes mortal, or sedative toxicity, like propofol infusion syndrome. This SEMICYUC Analgesia and Sedation Work Group recommends not administering more than 4.5 mg/kg/h of propofol or 0.25 mg/kg/h of midazolam. The need to use more than these doses should force a change in the sedative or the combined administration of both. Depending on the clinical situation or the clinical patient’s evolution, the use of clonidine, haloperidol or remifentanil could be better options (AU)

Delirio en el paciente crítico / Delusion in the critical patient

El delirio o síndrome confusional agudo es un problema frecuente en los enfermos críticos, aunque su diagnóstico a menudo se pasa por alto, es- pecialmente en su forma hipoactiva. Son factores de riesgo de delirio las alteraciones cognitivas previas y determinadas comorbilidades, distintos factores ambientales y las alteraciones orgánicas agudas propias del enfermo crítico. El delirio se asocia a un aumento de la mortalidad a corto y largo plazo, a la prolongación de la ventilación mecánica, a estancias prolongadas en la Unidad de Cuidados Intensivos (UCI) y en el hospital y a un deterioro cognitivo tras el alta hospitalaria. En los últimos años se han desarrollado herramientas específicas para la detección del delirio en la UCI, como el ICDSC y el CAM-ICU, que son aplicables incluso a los pacientes sometidos a ventilación mecánica. La puesta en práctica de intervenciones específicas sobre determinados factores de riesgo puede reducir la incidencia del delirio en enfermos hospitalizados. El tratamiento del delirio se basa en identificar y corregir las causas subyacentes, establecer medidas de soporte y, en ocasiones, el tratamiento farmacológico para el control de los síntomas. El haloperidol es el fármaco de primera línea para el control del delirio, pues la experiencia con los neurolépticos atípicos, como la olanzapina y la risperidona, así como con otros fármacos, es insuficiente para poder hacer recomendaciones sobre su uso. Los neurolépticos pueden presentar efectos secundarios graves que deben ser tenidos en cuenta. En los casos que cursan con agitación puede ser necesario el uso simultáneo de benzodiacepinas o propofol y, en ocasiones, de manera temporal y protocolizada, el uso de restricciones físicas (AU)

Delirium, the acute confusional syndrome, is a common although infradiagnosed problem in the critically ill patient, especially the hypoactive subtype. Risk factors for delirium are previous cognitive disturbances, some comorbidities, ambiental factors and the acute organic alterations of critical illness. Delirium is associated to an increase in short and long term mortality, prolongation of mechanical ventilation, increased Intensive Care Unit (ICU) and hospital length of stay, and cognitive impairment after hospital discharge. In the last years several tools have been developed to detect delirium in critically ill patients. The Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for ICU patients (CAM-ICU) have been validated and are useful even in patients receiving mechanical ventilation. Some interventions on specific risk factors can decrease the incidence of delirium in hospitalized patients. Treatment of delirium is based on the identification and correction of contributing factors, the introduction of support measures, and pharmacological therapy for symptomatic control. Halloperidol is the first line therapy of delirium in the critically ill patient, while experience with atypical neuroleptics and other drugs is limited, precluding to do recommendations about its use. Neuroleptic drugs can produce severe side effects and need careful dosage and monitoring. When agitation is important, can be necessary the simultaneous use of benzodiacepines or propofol, and some times, the temporal and protocolized application of physical restraints (AU)

Farmacología de los coloides sintéticos / Pharmacology of synthetic colloids

La reposición del volumen intravascular constituye uno de los pilares básicos en la resucitación de los pacientes en shock. El tipo de fluido a emplear, cristaloides o coloides, es objeto de controversia. Los coloides contienen partículas con un peso molecular elevado y, como consecuencia, ejercen una presión oncótica en el espacio intravascular. Este efecto va a depender de la concentración del fármaco administrado y del peso molecular. Por otro lado, también pueden ocasionar efectos adversos hematológicos, renales y reacciones alérgicas. En esta revisión, se describen algunos de los aspectos más relevantes de los tres tipos de coloides sintéticos empleados actualmente: almidones, gelatinas y dextranos. Los almidones proceden de la amilopectina del almidón. Hay disponibles almidones de alto (450.000 daltons), medio (200.000 –250.000) y bajo (75.000 – 150.000) peso molecular. La modificación de los radicales hidróxilo por hidroxietilo, en los carbonos C2,C3,C6de las moléculas de glucosa, condiciona las diferentes características farmacocinéticas y farmacodinamias de los almidones. Las gelatinas proceden de la degradación del colágeno animal. Su peso molecular oscila entre 15.000 y 90.000 daltons. Son los coloidesasociados con mayor incidencia de reacciones alérgicas; además, su obtención a partir de huesos bovinos (..) (AU)

Intravascular volume replacement is one of the basic cornerstones in the resuscitation of shock patients. The type of fluid, whether crystalloids or colloids, to be used is still a subject of debate. Colloids contain particles with high molecular weights, and thus exertan oncotic pressure on the intravascular space; this effect depends both on the concentration and on the molecular weight of the administered substance. On the other hand, these preparations may also induce haematological, renal and allergic adverse side effects. The present review examines some of the more relevant aspects of the three currently used types of synthetic colloids (starches, gelatins and dextrans). The starches are derived from the amylopectin of natural starch, and preparations with high (450,000 daltons), intermediate(200,000-250,000 daltons) and low (75,000-150,000 daltons)molecular weight are available. The substitution of hydroxyethylradicals for the hydroxyl ones in the C2, C3 and C6 carbonatoms of the glucose molecules gives rise to the varying pharmacokinetic and pharmacodynamic properties of the starch molecules. Gelatins are prepared by degradation of animal collagen; their molecular weights range from 15,000 to 90,000 daltons. Gelatins are the colloids most frequently associated to allergic reactions; furthermore, the fact that they are prepared from bovine bone causes doubts and concern regarding the possibility of transmission of(..) (AU)