Morbilidad materna grave e ingreso a cuidado intensivo: Hospital Clínico Universidad de Chile (2006-2010) / Intensive care admissions due to severe maternal morbidity

Background: Maternal morbidity is a quality of care indicator. The frequency of severe maternal morbidity that requires an intensive care management has increased, due to an increase in maternal age. Aim: To describe the severe and acute maternal morbidity spectrum that requires an intensive care management in a University Hospital. Material and Methods: Review of medical records of 89 pregnant women with a mean age of 29 years, admitted to an Intensive Care Unit (UCI) between 2006 and 2010. Results: Mean gestational age on admission was 32 weeks. The main comorbidities identified were chronic hypertension (13.5%), hypothyroidism (4.5%) and coagulopathies (6.7%). Severe preeclampsia, sepsis and obstetric hemorrhage were the main causes of admission. Length of stay ranged from 1 to 28 days. Seventy eight percent of patients were admitted in the immediate postnatal period. Mechanical ventilation was required in 24% of patients for a median of three days. The longer unit lengths of stay were observed in patients with preeclampsia and non-obstetric severe sepsis (pyelonephritis and pneumonia). Seven abortions and seven perinatal deaths were recorded. The latter were mainly secondary to severe preeclampsia/ HELLP syndrome. Neonatal morbidity was related to prematurity (19% hyaline membrane, 18% persistent ductus and 4% cerebral hemorrhage). There were no maternal deaths. Conclusions: Preeclampsia and its complications were the main causes of maternal ICU admission. In this series, there were no maternal deaths and the perinatal survival rate was 92%.

[Ministry of Health Intensive Care Medicine Commission: proposals for the development of the discipline]. / Medicina intensiva en Chile: desafíos para su desarrollo. Documento de la Comisión Nacional de Medicina Intensiva del Ministerio de Salud.

Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline.

Medicina intensiva en Chile: desafíos para su desarrollo. Documento de la Comisión Nacional de Medicina Intensiva del Ministerio de Salud / Ministry of Health Intensive Care Medicine Commission: Proposals for the development of the discipline

Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline.

[Intensive care admissions due to severe maternal morbidity]. / Morbilidad materna grave e ingreso a cuidado intensivo: Hospital Clínico Universidad de Chile (2006-2010).

BACKGROUND: Maternal morbidity is a quality of care indicator. The frequency of severe maternal morbidity that requires an intensive care management has increased, due to an increase in maternal age. AIM: To describe the severe and acute maternal morbidity spectrum that requires an intensive care management in a University Hospital. MATERIAL AND METHODS: Review of medical records of 89 pregnant women with a mean age of 29 years, admitted to an Intensive Care Unit (UCI) between 2006 and 2010. RESULTS: Mean gestational age on admission was 32 weeks. The main comorbidities identified were chronic hypertension (13.5%), hypothyroidism (4.5%) and coagulopathies (6.7%). Severe preeclampsia, sepsis and obstetric hemorrhage were the main causes of admission. Length of stay ranged from 1 to 28 days. Seventy eight percent of patients were admitted in the immediate postnatal period. Mechanical ventilation was required in 24% of patients for a median of three days. The longer unit lengths of stay were observed in patients with preeclampsia and non-obstetric severe sepsis (pyelonephritis and pneumonia). Seven abortions and seven perinatal deaths were recorded. The latter were mainly secondary to severe preeclampsia/ HELLP syndrome. Neonatal morbidity was related to prematurity (19% hyaline membrane, 18% persistent ductus and 4% cerebral hemorrhage). There were no maternal deaths. CONCLUSIONS: Preeclampsia and its complications were the main causes of maternal ICU admission. In this series, there were no maternal deaths and the perinatal survival rate was 92%.

Traumatismo materno grave y cirugía múltiple con resultado perinatal exitoso / Multiple surgery in severe maternal trauma with successful perinatal outcome

El traumatismo mayor de la embarazada es frecuente, tiene riesgo de muerte y agrega a sus complicaciones propias, las generadas por el embarazo como prematurez, desprendimiento placentario y daño perinatal. Presentamos el caso de una embarazada de 27 semanas, con traumatismo grave por atropello, fracturas óseas y desforramiento extenso de extremidad inferior derecha, que fue sometida a tratamiento quirúrgico con reducción y corrección de luxofracturas, aseo e injertos cutáneos. Se complica con infección grave de foco cutáneo, persistente, permaneciendo 24 días en Unidad de Cuidad Intensivo (UCI) en tratamiento antibiótico, 10 drenajes quirúrgicos, nutrición enteral y manejo continuo del dolor, antes del parto. Inicia síndrome de respuesta inflamatoria sistémica y se efectúa operación cesárea. El recién nacido prematuro pesó 1500 gramos y evolucionó favorablemente. En su puerperio permanece 60 días hospitalizada en UCI con 14 cirugías de reparación y mejoría completa. Se analiza las características singulares de morbilidad materna del caso, discutiendo los aspectos obstétricos, quirúrgicos y de cuidado intensivo, la evolución materna, el manejo de la infección y el rol de la cirugía en la prolongación del embarazo y su influencia en el resultado perinatal exitoso. Se concluye la importancia de la integración multidisciplinaria en la toma de decisiones médicas y quirúrgicas en el manejo del trauma materno grave.

Maternal trauma is a leading cause of morbidity and mortality for both, fetus and mother. In addition, trauma can generate risks as premature delivery, abruptio placentae and fetal damage. A pregnant women, at 27 gestational weeks had a car accident with dislocation and fractures and extensive skinning of right leg. The first surgery for fracture-dislocations, cleaning and muscle skin flap were complicated with infection from cutaneous focus, serious and persistent. She remainded for 24 days in Intensive Care Unit (ICU) with antibiotic therapy; she had 10 procedures of surgical drainage with anesthesia, catheter enteral nutrition and continuous pain medication before delivery. Then, she presented systemic inflammatory syndrome maternal and a cesarean section was done; the newborn weighted 1500 grams and had a favorable evolution. After delivery the mother stayed 60 days in ICU, with 14 reparatives surgeries and complete recovery. In this special patient with severe maternal morbidity we discuss the etiology of the oligoamnios observed, the maternal evolution in ICU, the handling of infection, the significance of surgical treatment in prolonging pregnancy and its influence on a successful perinatal outcome. We emphasize on the importance of a multidisciplinary approach in making the medical and surgical decisions in severe maternal trauma.

Traqueostomía percutánea en la Unidad de Cuidados Intensivos / Percutaneous dilatational tracheostomy in the Intensive Care Unit

El desarrollo de las diversas técnicas de traquesotomía percutánea ha facilitado la ejecución de este procedimiento en pacientes críticos sometidos a ventilación mecánica, y ha demostrado ser tanto o más seguro que la traqueostomía abierta en este grupo de enfermos. La traqueostomía percutánea ofrece beneficios adicionales, evitando la necesidad de movilizar a los pacientes a pabellón, acelerando su ejecución y mejorando la utilización de los recursos. En la actualidad la traqueostomía percutánea realizada en la Unidad de Cuidados Intensivos constituye el abordaje de elección para los pacientes críticos. La técnica de Ciaglia Blue Rhino es la modalidad de traqueostomía percutánea por dilatación más difundida a nivel mundial y la que presenta el mejor perfil de seguridad. La asistencia fibrobroncoscópica mejora la seguridad del procedimiento. Algunos pacientes seleccionados pueden beneficiarse de una evaluación previa con ecodoppler cervical. En la actualidad, la evidencia disponible sugiere fuertemente que la realización de una traqueostomía temprana puede reducir los días de ventilación mecánica y la estadía en la Unidad de Cuidados Intensivos, sin embargo aún quedan dudas sobre su verdadero impacto en la incidencia de neumonía asociada a ventilación mecánica y en la reducción de la mortalidad. En manos de un intensivista experimentado las contraindicaciones relativas clásicas no deberían ser un impedimento para la realización de una traqueostomía percutánea, ya que puede ser practicada con seguridad incluso en pacientes críticos de alto riesgo.

The development of various techniques of percutaneous dilatational tracheostomy has facilitated the implementation of this procedure in critically ill patients undergoing mechanical ventilation. Percutaneous dilatational tracheostomy provides additional benefits by avoiding the need to mobilize patients to the operating room, speeding implementation and improving resource utilization. Percutaneous dilatational tracheostomy has proven to be as safe as open surgical tracheostomy in critically ill patients undergoing mechanical ventilation; therefore it seems to be a more suitable approach for these patients. Ciaglia Blue Rhino technique is the most widespread method of percutaneous dilatational tracheostomy around de world and which has the best safety profile. Fiberoptic bronchoscopy assistance and preliminary cervical ultrasound examination in selected patients improve the safety of the procedure. Currently, the available evidence strongly suggests that performing an early tracheostomy may shorten the duration of mechanical ventilation and length of stay on the Intensive Care Unit. However, there are still doubts about its real impact on the incidence of ventilator-associated pneumonia, and in reducing mortality. In hands of an experienced intensivist relative contraindications should not be an impediment to perform a percutaneous dilatational tracheostomy, since it can be performed safely even in high risk critically ill patients.

Traqueostomía percutánea con asistencia fibrobroncoscópica en pacientes críticos de alto riesgo: seguridad de las indicaciones extendidas / Percutaneous dilatational tracheostomy with fiberoptic bronchoscopy assistance in high-risk critically ill patients

Introducción: La traqueostomía percutánea (TP) por dilatación es el método de elección en pacientes críticos que requieren la instalación de una traqueostomía. Sin embargo, una proporción importante de pacientes presentan habitualmente una o más contraindicaciones relativas para la realización de este procedimiento. Objetivo: Comparar la incidencia de complicaciones perioperatorias asociadas a la TP con la técnica de Ciaglia Blue Rhino y asistencia fibrobroncoscópica en pacientes críticos de alto riesgo versus pacientes críticos de bajo riesgo. Pacientes y Método: Se evaluaron en forma prospectiva 180 pacientes sometidos a una TP electiva debido a ventilación mecánica prolongada. Todas las TP fueron realizadas en la Unidad de Pacientes Críticos por un intensivista experimentado en el procedimiento y mediante un abordaje estandarizado. Se registraron variables demográficas, APACHE II, días de ventilación mecánica antes de la TP y la tasa de complicaciones perioperatorias. Resultados: La incidencia de complicaciones operatorias para los pacientes de alto y bajo riesgo fue 4,5 por ciento (3/67) y 5,2 por ciento (6/114), respectivamente (p = 0,81). No se registraron complicaciones operatorias graves, ni muertes asociadas al procedimiento. La incidencia de complicaciones postoperatorias fue 3 por ciento (2/67) para los pacientes de alto riesgo vs. 2,6 por ciento (3/114) para los pacientes de bajo riesgo (p =0,89). La incidencia global de complicaciones perioperatorias fue 7,5 por ciento (5/67) y 7,9 por ciento (9/114) para los pacientes de alto y bajo riesgo, respectivamente (p = 0,92).Conclusión: La TP por dilatación con la técnica de Ciaglia Blue Rhino modificada y asistencia fibrobroncoscópica es segura en pacientes críticos de alto riesgo, cuando es realizada por un intensivista experimentado mediante un abordaje estandarizado.

Background: Percutaneous dilatational tracheostomy (PDT) is the method of choice in critically ill patients requiring the installation of a tracheostomy. However, a significant proportion of patients usually have one or more relative contraindications for this procedure. Objective: To compare the incidence of perioperative complication of PDT with the modified Ciaglia Blue Rhino technique and fiberoptic bronchoscopy assistance in high-risk critically ill patients versus low-risk critically ill patients. Patients and Methods: We prospectively evaluated 180 patients undergoing an elective PDT due to prolonged mechanical ventilation. All of the PDT were performed in the Critical Care Unit for an intensivist experienced in the procedure, using a standardized approach. We recorded demographic variables, APACHE II, days of mechanical ventilation before the PDT and the rate of perioperative complications. Results: The incidence of operative complications for patients high and low risk was 4.5 percent (3/67) and 5.2 percent (6/114), respectively (p =0.81). There were no serious operative complications or deaths associated with the procedure. The incidence of postoperative complications was 3 percent (2/67) for high risk patients vs 2.6 percent (3/114) for low risk patients (p=0.89). The overall incidence of perioperative complications was 7.5 percent (5/67) and 7.9 percent (9/114) for patients at high and low risk, respectively (p =0.92). Conclusions: PDT with the modified Ciaglia Blue Rhino technique and fiberoptic bronchoscopy assistance is safe in critically ill patients at high risk, when performed by an experienced intensivist using a standardized approach.

Traqueostomía en el paciente crítico / Tracheostomy in the critical patient

Tracheostomy has evolved from a complex surgical intervention traditionally performed in the operating room, to a bedside procedure that can be done in the Intensive Care Unit, through a percutaneous approach. Percutaneous tracheostomy has proven to be as safe as open surgical tracheostomy in critically ill patients undergoing mechanical ventilation; therefore it seems to be a more suitable approach for these patients because it avoids the need of mobilizing patients outside their units and is performed in less time. Ciaglia Blue Rhino technique is the most widespread method of percutaneous dilatational tracheostomy, and exhibits an adequate safety profile. Fiberoptic bronchoscopy assistance and preliminary cervical ultrasound examination in selected patients improve the safeness of the procedure. Currently, the available evidencestrongly suggests that achieving an early tracheostomy may shorten mechanical ventilation days and stay in the Intensive Care Unit, but a decline in ventilator-associated pneumonia incidence and overall mortality reduction remains to be proven. In hands of an experienced intensivist, relative contraindications should not be an impediment to perform a percutaneous tracheostomy, since it can be performed safely even in high risk critically ill patients. Recently completed studies and those close to be finished, will provide interesting data on this significant topic.

[Fiberoptic bronchoscopy assisted percutaneous tracheostomy: report of 100 patients]. / Traqueostomía percutánea con asistencia fibrobroncoscópica: Evaluación prospectiva de 100 casos consecutivos y revisión de la literatura.

BACKGROUND: Development of percutaneous techniques for tracheostomy have facilitated its implementation in the intensive care unit (ICU). AIM: To evaluate the safety of performing percutaneous tracheostomy (PT) using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance in patients with prolonged mechanical ventilation. PATIENTS AND METHODS: Prospective evaluation of 100 consecutive patients aged 62+/-16 years (38 women) subjected to percutaneous tracheostomy. All the procedures were performed in the ICU. Demographic variables, APACHE II, days of mechanical ventilation before PT, operative and post-operative complications were recorded. RESULTS: Mean APACHE II score was 20+/-3. Patients required on average 16+/-7 days of mechanical ventilation before PT. Eight patients (8%) had operative complications. One had an episode of transitory desaturation, one had a transitory hypotension related to sedation and six had mild bleeding not requiring transfusion. No patient required conversion to surgical tracheostomy. Four patients (4%) presented post-operative complications. Two had a mild and transitory bleeding of the ostomy and two had a displacement of the cannula. No other complications were observed. CONCLUSIONS: PT using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance is a safe procedure that can be performed in the ICU by trained intensivists.

Traqueostomía percutánea con asistencia fibrobroncoscópica: evaluación prospectiva de 100 casos consecutivos y revisión de la literatura / Fiberoptic bronchoscopy assisted percutaneous tracheostomy: report of 100 patients

Background: Development of percutaneous techniques for tracheostomy have facilitated its implementation in the intensive care unit (ICU). Aim: To evaluate the safety of performing percutaneous tracheostomy (PT) using the Ciaglia Blue Rhino thechnique with fiberoptic bronchoscopy assistance in patients with prolonged mechanical ventilation. Patients and methods: Prospective evaluation of 100 consecutive patients aged 62±16 years (38 women) subjected to percutaneous tracheostomy. AU the procedures were performed in the ICU. Demographic variables, APACHE II, days of mechanical ventilation before PT, operative and post operative complications were recorded. Results: Mean APACHE II score was 20±3. Patients required on average 16±7 days of mechanical ventilation before PT. Eight patients (8 percent) had operative complications. One had an episode of transitory desaturation, one had a transitory hypotension related to sedation and six had mild bleeding not requiríng transfusión. No patient required conversión to surgical tracheostomy. Four patients (4 percent) presentedpost operative complications. Two had a mild and transitory bleeding ofthe ostomy and two had a displacement ofthe cannula. No other complications were observed. Conclusions: PT using the Ciaglia Blue Rhino technique with fiberoptic bronchoscopy assistance is a safe procedure that can be performed in the ICU by trained intensivists.

[Severe lactic acidosis caused by propofol infusion: report of one case]. / Acidosis láctica severa asociada a infusión de propofol: Caso clínico.

Propofol infusion syndrome (PRIS) is a rare but potentially lethal complications. This disorder is triggered under unknown circumstances by a propofol infusion of more than 5 mg/kg/h for more than 48 h. PRIS is characterized by a multiorgan failure and rhabdomyolysis and is induced by a disturbance in mitochondrial long chain fatty acid oxidation. We report a 43 year-old woman who underwent brain surgery due to a vascular malformation. In the immediate postoperative period, she had an unexplained and severe lactic acidosis. During anaesthesia, she received a propofol infusion of 7 mg/kg/h that continued in the UCI at a rate of 3.5 mg/kg/h, for 8 hours more. The suspicion of PRIS motivated immediate discontinuation of propofol with rapid correction of lactic acidosis and full recovery of the patient.

Acidosis láctica severa asociada a infusión de propofol: Caso clínico / Severe lactic acidosis caused by propofol infusion: Report of one case

Propofol infusion syndrome (PRIS) is a rare but potentially lethal complications. This disorder is triggered under unknown circumstances by a propofol infusion of more than 5 mg/kg/h for more than 48 h. PRIS is characterized by a multiorgan failure and rhabdomyolysis and is induced by a disturbance in mitochondrial long chain fatty acid oxidation. We report a 43 year-old woman who underwent brain surgery due to a vascular malformation. In the immediate postoperative period, she had an unexplained and severe lactic acidosis. During anaesthesia, she received a propofol infusion of 7 mg/kg/h that continued in the UCI at a rate of 3.5 mg/kg/h, for 8 hours more. The suspicion of PRIS motivated immediate discontinuation of propofol with rapid correction of lactic acidosis and full recovery of the patient.

Reanimación protocolizada del shcok séptico / Protocolized reanimation of septic shock

Severe sepsis and septic shock are pathologies with an increasing incidence in the world. Annually, in the USA 200.000 people die because of severe sepsis, the same number that die because of a myocardial infarction, being this last disease much more common. In Chile, a multicentric study found a 40 percent of prevalence of severe sepsis in critically ill patients, with amortality of 27 percent. In this scenario, it becomes of great importance the appropriate and integral management of this condition, by means of an early diagnosis and the implementation of anaggressive protocolized resuscitation, guided by clear goals. During the first stage of the resuscitation cristalloids and/ or colloids can be used, in order to expand the intravascular space, searching for CVP around 8 to 12 mmHg. In case of hypotension refractory to the administration of fluids, it is recommended to start with increasing doses of norepinephrin untila MAP of 65 - 75 mmHg is achieved. The intensity of the septic shock can be stratified according to the requirements of norepinephrine. It is of great importance to obtain blood cultures of the patients and to start with empiric antibiotic therapy as soon as possible. The initial metabolic goal must be the normalization of the central venous oxygen saturation. The implementation of the resuscitation bundle during the first six hours, since the diagnose of severe sepsis is done, increases the chances of surviving. Protocols of sedation and analgesia, and the use of protective mechanical ventilation is highly recommended. The use of hydrocortisone and human recombinant protein C in selected patients, may have a beneficial result in the outcome.Vasopressin, terlipressin and high-volume hemofiltration can be used as rescue measures for the most severe patients.

Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: Primer estudio nacional multicéntrico / Prevalence of severe sepsis in Intensive Care Units: A national multicentric study

Background: Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). Aim: To study the prevalence of SS in Chilean ICUs. Material and methods: An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Results: Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66 percent. Mean age of patients was 57.7+18 years and 59 percent were male, APACHE II score was 15+7.5 and SOFA score was 6+4. SS was the admission diagnosis of 94 of the 283 patients (33 percent) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40 percent). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9 percent (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7 percent (30/112) and 8.7 percent (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48 percent respiratory and 30 percent abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. Conclusions: SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APA CHE II and SOFA scores were independent predictors of mortality.

Necrosis intestinal como presentación de enfermedad de Takayasu / Intestinal necrosis as clinical presentation of Takayasuïs arteritis: report of one case

A 32 years old female was admitted to hospital due to acute abdominal pain, nausea, vomiting and liquid stools. Physical examination was normal except for pain on her left inferior abdominal quadrant without peritoneal irritation signs. An abdominal CAT-scan suggested thrombosis at celiac trunk, although the echo Doppler showed no alterations except for signs of ischemia in the distal branch of the superior mesenteric artery. An exploratory laparotomy was performed disclosing a necrosis of the distal ileum and cecum, diffuse peritonitis and thrombosis of the ileocecoapendiculocolic artery. No vasculitis lesions were found in the arteries of medium size examined. A history of intermittent claudication for the past 3 years as well as acrocyanosis, asymmetry of pulses and blood pressure in the superior extremities was ascertained after the surgery. A MRI angiogram showed multiple stenoses and irregularities at the celiac trunk, hepatic, superior mesenteric and fibular arteries. No abnormalities at the aortic arch and its main branches were documented. A sepsis due to Candida sp complicated her postoperatory period. After recovery, prednisone 1 mg/kg/day was started and the anticoagulation continued. The abdominal pain, intermittent claudication and superior limb acrocyanosis disappeared. This is an unusual case of type IV Takayasu's arteritis with acute abdominal signs as the first manifestation

Neumonía adquirida en la comunidad: comunicación de 8 casos de neumonía grave por legionella pneumophila serogrupo 1 en Chile / Community acquired pneumonia: report of 8 cases of severe pneumonia caused by legionella pneumophila seroproup 1 in Chile

Legionella pneumophila is the second cause of severe community acquired pneumonia. In Chile, however, there are few reports of pneumonia caused by Legionella. We report eight patients (6 men, aged 42 to 72 years old) with community-acquired pneumonia caused by Legionella pneumophila serogroup 1, confirmed by the measurement of urinary antigen. Clinical presentation was characterized by fever or hypothermia (in one case), cough, dyspnea and neurological abnormalities in four patients. Cigarette smoking was the most frequently identified risk factor. All patients had at least one American Thoracic Society severity criteria. Complications observed were acute hypoxemic respiratory failure in seven patients, shock in four, renal failure in four and need for mechanical ventilation in three. No patient died