ABSTRACT
La evolución del tratamiento de oxigenación por membrana extracorpórea (ECMO) y en particular del transporte de los pacientes sometidos a él, ha cambiado de forma significativa en la última década y lo ha hecho de manera desigual en diferentes regiones. Se ha demostrado que la creación de centros de referencia especializados mejora los resultados. Por todo ello ha sido necesario crear redes de equipos especializados y el número de transportes secundarios de pacientes con este tratamiento está en aumento. Con el fin de mejorar la calidad del tratamiento y ofrecer una guía para los servicios que intervienen en estos transportes, los grupos de trabajo de transporte crítico de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) han realizado un trabajo conjunto de elaboración de estas recomendaciones, enfocadas a los siguientes aspectos: indicaciones, sistemas de centros de referencia, medios de transporte, características y equipamiento, equipos humanos, formación y seguridad clínica (AU)
The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety (AU)
Subject(s)
Humans , Extracorporeal Membrane Oxygenation , Critical Care , Transportation of Patients/methods , Societies, Medical , Consensus , SpainABSTRACT
The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety.
Subject(s)
Extracorporeal Membrane Oxygenation , Child , Consensus , Critical Care , Extracorporeal Membrane Oxygenation/adverse effects , HumansABSTRACT
The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.
Subject(s)
Antiviral Agents/therapeutic use , Influenza A Virus, H1N1 Subtype , Influenza, Human/diagnosis , Influenza, Human/therapy , Intensive Care Units , Adrenal Cortex Hormones/therapeutic use , Algorithms , Bacterial Infections/complications , Bacterial Infections/drug therapy , Extracorporeal Membrane Oxygenation , Humans , Influenza Vaccines/adverse effects , Influenza, Human/complications , Influenza, Human/mortality , Influenza, Human/virology , Prognosis , Respiration, Artificial , Respiratory Distress Syndrome/drug therapy , Respiratory Distress Syndrome/virology , Risk Factors , Severity of Illness IndexABSTRACT
AIMS: To describe the demographic characteristics of patients with spontaneous subarachnoid haemorrhage (SAH) in our population and to compare the endovascular and surgical treatment of intracranial aneurysms. PATIENTS AND METHODS: We conducted a retrospective study of 462 patients who were admitted to the Hospital Universitario La Fe in Valencia between April 1997 and March 2005. RESULTS: The mean age was 56.8 +/- 14.8 years and 55.8% of the patients were females. The risk factors were: arterial hypertension, 40.3%; smoking, 32.7%; dyslipidemia, 16.0%; diabetes mellitus, 10.6%; alcoholism, 6.7%. A cerebral arteriography was performed in 369 patients and intracranial aneurysms were detected in 246 of them. Aneurysms were treated by embolisation in 62.6% of cases and by surgery in 22%. On comparing the embolisation and surgery groups, there were non-significant differences in the rates of complications. Infections were present in 21.9% of patients in the embolisation group versus 10.2% in the surgery group; epileptic seizures 6.1% versus 8%; hydrocephalus 2.7% versus 4%; rebleeding 4.1% versus 10.2%; clinical vasospasm 8.9% versus 6.1%. The rate of sequelae on discharge (a score on the modified Rankin Scale > 3) was 13.7% among surviving patients in the embolisation group and 15.5% in the group that had undergone surgery. The mortality rates in the two groups were 10.3 and 10%, respectively. Overall mortality rate was 30.1%. CONCLUSIONS: The presentation and course of SAH in our population follow a pattern that is similar to those reported in other countries. No differences in morbidity and mortality were detected between the endovascular and surgical treatment of ruptured intracranial aneurysms.
Subject(s)
Subarachnoid Hemorrhage , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Intracranial Aneurysm/complications , Intracranial Aneurysm/diagnosis , Intracranial Aneurysm/therapy , Male , Middle Aged , Retrospective Studies , Subarachnoid Hemorrhage/diagnosis , Subarachnoid Hemorrhage/etiology , Subarachnoid Hemorrhage/therapyABSTRACT
Objetivos. Describir las características demográficas de los pacientes con hemorragia subaracnoidea (HSA) espontánea en nuestro medio y comparar los tratamientos endovascular y quirúrgico de los aneurismas intracraneales. Pacientes y métodos. Estudio retrospectivo de 462 pacientes ingresados en el Hospital Universitario la Fe de Valencia entre abril de 1997 y marzo de 2005. Resultados. La edad media fue de 56,8 ± 14,8 años. El 55,8% de los pacientes eran mujeres. Los factores de riesgo fueron: hipertensión arterial 40,3%, tabaquismo 32,7%, dislipemia 16,0%, diabetes mellitus 10,6%, alcoholismo 6,7%. La arteriografía cerebral se realizó a 369 pacientes y se detectó aneurisma intracraneal en 246. Un 62,6% de los aneurismas fue embolizado y un 22% intervenido quirúrgicamente. Al comparar los grupos de embolización y cirugía, hubo diferencias no significativas en las tasas de complicación. Presentaron infección 21,9% de pacientes en el grupo de embolización frente a 10,2% en el grupo quirúrgico, crisis epiléptica 6,1% frente a 8%, hidrocefalia 2,7% frente a 4%, resangrado 4,1% frente a 10,2%, vasoespasmo clínico 8,9% frente a 6,1%. La tasa de secuelas al alta (puntuación en la escala de Rankin modificada > 3) fue de 13,7% entre los pacientes supervivientes del grupo de embolizados y 15,5% en el grupo de intervenidos. La mortalidad en cada grupo fue 10,3 y 10%, respectivamente. La mortalidad global alcanzó el 30,1%. Conclusiones. La presentación y evolución de la HSA en nuestro medio sigue un patrón comparable al de otros países. No hemos detectado diferencias de morbimortalidad entre abordajes endovascular y quirúrgico de los aneurismas intracraneales rotos (AU)
Aims. To describe the demographic characteristics of patients with spontaneous subarachnoid haemorrhage (SAH) in our population and to compare the endovascular and surgical treatment of intracranial aneurysms. Patients and methods. We conducted a retrospective study of 462 patients who were admitted to the Hospital Universitario La Fe in Valencia between April 1997 and March 2005. Results. The mean age was 56.8 ± 14.8 years and 55.8% of the patients were females. The risk factors were: arterial hypertension, 40.3%; smoking, 32.7%; dyslipidemia, 16.0%; diabetes mellitus, 10.6%; alcoholism, 6.7%. A cerebral arteriography was performed in 369 patients and intracranial aneurysms were detected in 246 of them. Aneurysms were treated by embolisation in 62.6% of cases and by surgery in 22%. On comparing the embolisation and surgery groups, there were non-significant differences in the rates of complications. Infections were present in 21.9% of patients in the embolisation group versus 10.2% in the surgery group; epileptic seizures 6.1% versus 8%; hydrocephalus 2.7% versus 4%; rebleeding 4.1% versus 10.2%; clinical vasospasm 8.9% versus 6.1%. The rate of sequelae on discharge (a score on the modified Rankin Scale > 3) was 13.7% among surviving patients in the embolisation group and 15.5% in the group that had undergone surgery. The mortality rates in the two groups were 10.3 and 10%, respectively. Overall mortality rate was 30.1%. Conclusions. The presentation and course of SAH in our population follow a pattern that is similar to those reported in other countries. No differences in morbidity and mortality were detected between the endovascular and surgical treatment of ruptured intracranial aneurysms (AU)
