[Is the permanent pacemaker implant more efficient in level 1 hospital?]. / ¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I?

OBJECTIVE: To determine if permanent pacemaker implants (PPM) interventions and change of generator are more efficient in small hospitals. DESIGN: A cost-effective analysis and retrospective, cross-sectional and observational study of diagnostic related groups (DRG). SETTING: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year 2007 provided by the Health Ministry. PATIENTS: This includes the total number of patients who required treatment in all national hospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome, heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but without changing the battery, 118- application of a new one, 549 - implementation or revision but with serious complications. PRINCIPAL VARIABLES OF INTEREST: demographic, clinical (number of secondary diagnoses (NSD) and procedures (NP), mortality) and management (total and preoperative length of stay (LOS), access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on the average. RESULTS: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between small hospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs 11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively (3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured by proxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic and therapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, there being an association with preoperative stay, NDS, NP and emergency access. CONCLUSION: Pacemaker implantation and generator change in small hospitals is more efficient, with internal consistency by subgroups.

Thrombocytopenia induced by pulmonary artery flotation catheters. A prospective study.

The platelet counts of patients with PAFC were studied prospectively, 45 patients admitted to the ICU during the same period of time, who did not require PAFC were used as a control group. We had previously excluded any other cause of thrombocytopenia in both groups of patients. We found a significant platelet decrease in the PAFC group at 6 h (p less than 0.001), 24 h (p less than 0.001), 48 h (p less than 0.001) and 72 h (p less than 0.001) after catheter placement, compared to the control group. This decrease was early and sharp and disappeared quickly after catheter removal. We believe that thrombocytopenia in these patients is of peripheral origin and is due to an increased consumption of platelets.

¿Estamos los intensivistas dejando de creer en los beneficios de la nutrición? / Are intensivists losing faith in the benefits of nutrition?

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[Recurrent refractory ventricular fibrillation: how many times is it necessary to defibrillate?]. / Fibrilación ventricular refractaria: ¿cuántas veces hay que desfibrilar?

Recurrent ventricular fibrillation is that which persists after three consecutive defibrillation attempts. It generally appears in almost 25% of all heart arrests and entails high mortality. Use of amiodarone during resuscitation maneuvers is recommended, this having better results than lidocaine. Neither procainamide nor bretylium should be used in this type of arrhythmia, however beta blockers or magnesium can be used when ischemic heart disease or hypomagnesiemia, respectively, is suspected as the cause. We present the case of a male patient with a background of heart disease (stent in circunflex 8 years earlier) that began with an episode of primary ventricular fibrillation when entering the Emergency Service. He was given 35 shocks of 360 J, without using thoracic compressions at any time since he recovered an effective post-shock pulse with normal neurological condition. Amiodarone and thrombolytics (tenecteplase) were administered during the intervention, achieving favorable resolution after 52 min, once stabilized showing an electrocardiogram of acute coronary syndrome without ST elevation and verifying obstruction of the right coronary artery in the catheterism, on which a stent was placed. He was discharged from the hospital six days after with no neurological sequels. In agreement with the 2005 International Liaison Committee on Resuscitation Recommendations, the resuscitation maneuvers and electrical shocks should be continued while there is a defibrillable rhythm, as occurred in our patient.

Los síndromes pericárdicos agudos en la unidad de cuidados intensivos / Acute pericardial syndromes in the intensive care unit

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[Economics and equity in urgency and emergency care]. / Economía y equidad en urgencias y emergencias.

The financial sustainability of public health systems (PHS) is currently threatened by population growth, increased prevalence of chronic conditions and disabilities, inequality in access and use of resources, zero cost delivery and global economic crisis. The emergency department (ED) is one for which demand is highest--without relation to the health model--because disease becomes established in disadvantaged socio-demographic areas and inequalities, hyperconsumption and decision making more closely linked to the user are maintained. The medical device of ED is a multiple one and its diverse product lines make it difficult to measure. This review discusses the need to deploy measurement tools in ED, where there are high direct costs--primarily structural--and other variables related to the activity, where the marginal cost is higher than the average and there is no economy of scale in such interventions. The possible mechanisms of private copayment in financing the supply of EDs are also studied, showing their advantages and disadvantages, with the conclusion that they are not recommendable--due to their scarce fund raising and deterrent capacity, which is why fundamental strategic changes in the management of these resources are needed.