Mechanical ventilation in acute respiratory distress syndrome: The open lung revisited.

Acute respiratory distress syndrome (ARDS) is still related to high mortality and morbidity rates. Most patients with ARDS will require ventilatory support. This treatment has a direct impact upon patient outcome and is associated to major side effects. In this regard, ventilator-associated lung injury (VALI) is the main concern when this technique is used. The ultimate mechanisms of VALI and its management are under constant evolution. The present review describes the classical mechanisms of VALI and how they have evolved with recent findings from physiopathological and clinical studies, with the aim of analyzing the clinical implications derived from them. Lastly, a series of knowledge-based recommendations are proposed that can be helpful for the ventilator assisted management of ARDS at the patient bedside.

Clinico-radiological related to early brain death factors.

OBJECTIVE: To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h. DESIGN: A retrospective cohort study was made covering the period 2015-2017. SETTING: An adult Intensive Care Unit (ICU). PATIENTS/METHODS: Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. RESULTS: A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. CONCLUSIONS: Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Clinico-radiological related to early brain death factors. / Factores clínico-radiológicos asociados con muerte encefálica precoz.

OBJECTIVE: To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours. DESIGN: A retrospective cohort study was made covering the period 2015-2017. SETTING: An adult Intensive Care Unit (ICU). PATIENTS/METHODS: Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. RESULTS: A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. CONCLUSIONS: Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

[Visitation policy, design and comfort in Spanish intensive care units]. / Política de visitas, diseño y confortabilidad en las unidades de cuidados intensivos españolas.

OBJECTIVE: To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care. DESIGN: Descriptive, multicentre study. SETTING: Spanish ICUs. METHODS: A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI. RESULTS: A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%. CONCLUSIONS: Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort.

[Sphincter function disorders. physiopathology and neurophysiological study]. / Trastornos de la funcion esfinteriana. Fisiopatología y estudio neurofisiológico.

Miction and defecation disturbances are very frequent in the general population and far more so among neurological patients. It is essential to know the physiopathology of these disorders in clinical practice. The neurological control of these functions is carried out by automatisms that are regulated in the nuclei of the brain stem through somatic and vegetative peripheral structures that act simultaneously. The cortical, hypothalamic and reticular levels play a part in the activation or inhibition of the pontine nuclei. Continence depends on the integrity of the anatomical structures and the sensory, pressure and mechanical systems that enable the automatisms to develop. Neurological examination must be combined with studies conducted by other specialists on patients in which no neurological illness is known, but who have this kind of dysfunction. Adding a neurophysiological examination allows us to complete the clinical study and to check objectively for the existence of external anal sphincter denervation or disorders involving the exteroceptive reflexes of the sacrum. The recent appearance of techniques for treating incontinence that make use of the repeated and continuous stimulation of the sacral roots has revolutionised the way these patients are treated and calls for greater involvement of neurologists in dealing with these problems.

Trastornos de la función esfinteriana. Fisiopatología y estudio neurofisiológico / Sphincter function disorders. Physiopathology and neurophysiological study

Las alteraciones funcionales de la micción y de la defecación son muy frecuentes en la población general, y mucho más entre los pacientes neurológicos. Es esencial para la práctica clínica conocerla fisiopatología de estos trastornos. El control neurológico de estas funciones se realiza a partir de automatismos regulados en los núcleos del tronco cerebral mediante estructuras periféricas somáticas y vegetativas que actúan simultáneamente. Los niveles corticales, hipotalámicos y reticulares influyen en la puesta en marcha o inhibición de los núcleos protuberanciales. La continencia depende de la integridad de las estructuras anatómicas y de los sistemas mecánicos, presivos y sensoriales que permiten el desarrollo de los automatismos. Debe incluirse el examen neurológico en los estudios que realizan otros especialistas en los pacientes con este tipo de disfunciones en los que no se conoce enfermedad neurológica. Añadir el examen neurofisiológico permite completar el estudio clínico y reconocer de forma objetiva la existencia de denervación del esfínter anal externo o de alteraciones en los reflejos exteroceptivos sacros. La aparición reciente de técnicas de tratamiento de la incontinencia que usan la estimulación repetitiva y continua de las raíces sacras ha revolucionado el enfoque terapéutico de estos pacientes, e incita a una mayor participación de los neurólogos en estos problemas (AU)