ABSTRACT
BACKGROUND: Esophageal pressure measurement is a minimally invasive monitoring process that assesses respiratory mechanics in patients with acute respiratory distress syndrome. Airway pressure release ventilation is a relatively new positive pressure ventilation modality, characterized by a series of advantages in patients with acute respiratory distress syndrome. CASE PRESENTATION: We report a case of a 55-year-old chilean female, with preexisting hypertension and recurrent renal colic who entered the cardiosurgical intensive care unit with signs and symptoms of urinary sepsis secondary to a right-sided obstructive urolithiasis. At the time of admission, the patient showed signs of urinary sepsis, a poor overall condition, hemodynamic instability, tachycardia, hypotension, and needed vasoactive drugs. Initially the patient was treated with volume control ventilation. Then, ventilation was with conventional ventilation parameters described by the Acute Respiratory Distress Syndrome Network. However, hemodynamic complications led to reduced airway pressure. Later she presented intraabdominal hypertension that compromised the oxygen supply and her ventilation management. Considering these records, an esophageal manometry was used to measure distending lung pressure, that is, transpulmonary pressure, to protect lungs. Initial use of the esophageal balloon was in a volume-controlled modality (deep sedation), which allowed the medical team to perform inspiratory and expiratory pause maneuvers to monitor transpulmonary plateau pressure as a substitute for pulmonary distension and expiratory pause and determine transpulmonary positive end-expiratory pressure. On the third day of mechanical respiration, the modality was switched to airway pressure release ventilation. The use of airway pressure release ventilation was associated with reduced hemodynamic complications and kept transpulmonary pressure between 0 and 20 cmH2O despite a sustained high positive end-expiratory pressure of 20 cmH2O. CONCLUSION: The application of this technique is shown in airway pressure release ventilation with spontaneous ventilation, which is then compared with a controlled modality that requires a lesser number of sedative doses and vasoactive drugs, without altering the criteria for lung protection as guided by esophageal manometry.
Subject(s)
Continuous Positive Airway Pressure , Respiratory Distress Syndrome , Female , Humans , Lung , Middle Aged , Respiration, Artificial , Respiratory Distress Syndrome/therapy , Respiratory MechanicsABSTRACT
Resumen: La pandemia COVID-19 nos ha obligado a replantearnos la manera en la que practicamos algunos aspectos de la medicina. La reanimación cardiopulmonar es una práctica que genera partículas en aerosol provenientes de la vía aérea, lo cual incrementa el riesgo de contagio por SARS-CoV-2. En esta revisión se consultan las recomendaciones internacionales sobre el tema, se definen momentos de alto riesgo y se establecen recomendaciones sobre compresiones, ventilación, terapia eléctrica e incluso farmacológica en pacientes con paro cardíaco y con diagnóstico de COVID-19, buscando no sólo el bienestar del paciente, sino también la seguridad del personal de salud.
Abstract: The COVID-19 pandemic has forced us to rethink the way we practice some aspects of medicine. Cardiopulmonary resuscitation is a practice that generates aerosol particles from the airway, which increases the risk of SARS-CoV-2 infection. In this review, the international recommendations on the subject are consulted, high-risk moments are defined and recommendations are established on compressions, ventilation, electrical therapy and even pharmacology in patients with cardiac arrest and with a diagnosis of COVID-19, seeking not only the well-being of the patient, but also the safety of health personnel.
ABSTRACT
Tigecycline is the first of a new class of antibiotics named glycylcyclines and it was approved for the treatment of complicated intra-abdominal infections and skin and skin structure infections and community-acquired bacterial pneumonia. Notwithstanding this, the tigecycline's pharmacological and microbiological profile encourage physicians' use of the drug in other infections. The aim of this study was to characterize the indications type, pathogens, and outcomes of patients who were treated with tigecycline. We analyzed the tigecycline prescriptions in 209 patients in 23 Latin American centres using an electronic form included in the website LatinUser (http://www.clinicalrec.com.ar). Sixty-six patients (31.5%) received tigecycline for approved indications, and 143 (68.5%) for "off label" indications (47% with scientific support and 21.5% with limited or without any scientific support). The most frequent "off label" use was ventilator-associated pneumonia (VAP) (76 patients). The etiology of infections was established in 88 patients (42%). Acinetobacter spp. (54.5%, in 65% of cases carbapenems-resistant), methicillin-resistant Staphylococcus aureus (12%), and extended spectrum ß-lactamases-producing Enterobacteriaceae (10%) were the most common microorganisms isolated. Overall, attending physicians reported clinical success in 144 of the 209 patients (69%). Global mortality proportion was 35,5% (74/209 patients). Our study shows that the off label use of tigecycline is frequent, especially in VAP due to multidrug-resistant pathogens, where the therapeutic options are limited (eg: carbapenems-resistant Acinetobacter spp.). Physicians must evaluate the benefits/risks to use this antibiotic for indications that lack rigorous scientific support.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacterial Infections/drug therapy , Minocycline/analogs & derivatives , Adolescent , Adult , Aged , Aged, 80 and over , Bacterial Infections/microbiology , Child , Critical Illness , Drug Resistance, Multiple, Bacterial , Female , Humans , Internet , Male , Middle Aged , Minocycline/therapeutic use , Off-Label Use , Pneumonia, Ventilator-Associated/drug therapy , Pneumonia, Ventilator-Associated/microbiology , Practice Patterns, Physicians'/statistics & numerical data , Registries , Retrospective Studies , Tigecycline , Treatment Outcome , Young AdultSubject(s)
Humans , Nutritional Support/methods , Nutritional Support/standards , Critical Care , Intensive Care Units , Chile , Consensus , Enteral Nutrition , Critical Illness/therapy , Monitoring, Physiologic , Nutrition Assessment , Nutritional Requirements , Nutritional Status , Parenteral Nutrition , Practice Guidelines as TopicABSTRACT
Presentamos dos pacientes con síndrome de Boerhaave. Este síndrome es una forma infrecuente de perforación esofágica. Presenta una alta morbimortalidad según el tiempo transcurrido hasta su diagnóstico. La anatomía distintiva hace que la mayor parte de las perforaciones tengan lugar en su tercio inferior cercano al diafragma. La tomografía computada de tórax es diagnóstica usualmente. Nuestros pacientes necesitaron cirugía y manejo en cuidados intensivos, en ellos se utilizó ventilación mecánica, drogas vasoactivas, nutrición parenteral prolongada y antibióticos de amplio espectro. El tratamiento quirúrgico más frecuente consiste en el cierre simple, la técnica de Thal, la exclusión bipolar intratorácica con drenajes o la esofagostomía cervical con esofaguectomía y alimentación por yeyunostomía, asociado o no con drenaje mediastínico a través de toracotomía.
Subject(s)
Humans , Male , Female , Esophagostomy , Esophageal Diseases/surgery , Esophageal Diseases/diagnosis , Rupture, Spontaneous , SyndromeSubject(s)
Humans , Male , Adult , Catheterization, Swan-Ganz , Endocardium/injuries , Endocarditis/diagnosis , Sepsis , Wounds, StabABSTRACT
Las arritmias cardíacas son comunes en los pacientes críticos, pudiendo ser benignas, en un comienzo, o fatales. Requieren de un diagnóstico rápido y exacto. Los intensivistas debemos estar familiarizados con su rápida identificación y manejo para una buena práctica clínica. Presentamos el caso de una mujer de 86 años, con antecedentes de Diabetes Mellitus II B e hipertensión arterial que ingresó a nuestra clínica con una neumonía basal derecha y brusca falla respiratoria, cuyo ecocardiograma muestra mínima insuficiencia aórtica, mitral y tricuspídea, con función sistólica global-segmentaria conservadas y cuya tomografía axial computada de tórax con énfasis vascular descartó tromboembolismo. Durante su evolución hospitalaria presentó arritmia extrasistólica supraventricular, fibrilación auricular, taquicardia ventricular y fibrilación ventricular, las que unidas a cambios electrocardiográficos, QT corregido de 714 mseg y troponina T de 0,018 llevaron al estudio coronario, demostrando su origen isquémico. Se analizan los electrocardiogramas y se discute el diagnóstico diferencial etiológico.
Subject(s)
Humans , Female , Aged , Anti-Arrhythmia Agents/therapeutic use , Electrocardiography , Long QT Syndrome/surgery , Long QT Syndrome/drug therapy , Tachycardia, Ventricular/diagnosis , Tachycardia, Ventricular/etiology , Angioplasty , Diabetes Mellitus, Type 2 , Isoproterenol/therapeutic use , Risk Factors , Tocainide/therapeutic useSubject(s)
Humans , Female , Aged , Echocardiography, Transesophageal , Pulmonary Embolism , Arthroplasty, Replacement, Hip , Dyspnea , Femoral Vein , Heparin , Leg , Pulmonary EmbolismABSTRACT
La historia de la reanimación cardiopulmonar (RCP) moderna se remonta a 40 años. Se han hecho esfuerzos para hacerla rápidamente accesibles a las personas que la requieran, desarrollando pautas claras y programas de entrenamiento para difundir de modo práctico un cuerpo conceptual. En el último tiempo se ha estado haciendo una reflexión crítica sobre las evidencias científicas en que se basan estas recomendaciones. En ausencia de pautas nacionales de RCP avanzadas tratamos de recoger tanto la revisión científica como las opiniones de expertos en una reciente reunión internacional que recomendaron nuevas pautas. Se comentas cambios en la reanimación básica, como no palpar pulso ni realizar maniobras para cuerpo extraño, o reanimación sólo con compresiones torácicas por reanimadores inexpertos y aumento de la frecuencia de comprensiones. Se discuten propuestas en reanimación avanzada, como la incorporación del masaje toracoabdominal, vasopresina, amiodarona o la disminución del volumen de ventilación
