Severe cefepime-induced status epilepticus treated with haemofiltration / Estatus epiléptico grave inducido por cefepime tratado con hemofiltración

Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA (AU)

La neurotoxicidad por cefepime puede producirse principalmente en pacientes con insuficiencia renal. Presentamos un caso de status epiléptico no convulsivo producido por cefepime. Una mujer de 65 años con fracaso renal agudo en tratamiento con cefepime sufrió un episodio grave de status epiléptico no convulsivo que requirió inducción de coma barbitúrico con tiopental sódico. Tras el cambio de cefepime a meropenem se produjo también una interacción grave entre meropenem y ácido valproico. Se utilizó hemofiltración venovenosa continua para acelerar el aclaramiento de cefepime y la paciente recuperó progresivamente su situación neurológica previa. En conclusión, la dosis de cefepime debe ser ajustada a la función renal para evitar toxicidad en pacientes con insuficiencia renal. Debería considerarse la utilización del electroencefalograma en casos de estado confusional agudo en pacientes en tratamiento con cefepime para un diagnóstico precoz del status epiléptico no convulsivo. La terapia continua de reemplazo renal puede ser empleada en casos graves para acelerar la eliminación de cefepime. Además el meropenem no debe de utilizarse concomitantemente con el ácido valproico (AU)

Severe cefepime-induced status epilepticus treated with haemofiltration.

Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA.

[Hemodynamic variability caused by pressure-volume plotting and alveolar recruitment maneuvers in patients with adult respiratory distress syndrome]. / Variaciones hemodinámicas inducidas por la realización de una curva presión-volumen y una maniobra de reclutamiento alveolar en pacientes con síndrome de distrés respiratorio agudo.

OBJECTIVES: The plotting of pressure-volume curves and the performance of alveolar recruitment maneuvers are common practices in the care of patients with adult respiratory distress syndrome (ARDS), even though potentially harmful hemodynamic effects are associated with sustaining a high intrathoracic pressure. Our aim was to analyze hemodynamic and ventilatory changes related to these 2 maneuvers and to assess the short-term effectiveness of recruitment. PATIENTS AND METHODS: The patients had ARDS and were being monitored with a catheter connected to a PiCCO system. All measurements were taken in sinus rhythm and with adequate vascular filling. Values recorded during plotting of the quasistatic pressure-volume curve and the recruitment maneuver (sustained airway pressure of 40 cm H2O) were the cardiac index, mean arterial pressure, heart rate, systolic volume index, and oxygen saturation (SpO2). Blood gas measurements were recorded before the maneuvers and 15 minutes afterwards. RESULTS: All parameters decreased significantly in the 14 patients studied. The mean (SD) maximum decreases, from which all patients recovered within 2 minutes, were as follows: cardiac index, 26% (16%); mean arterial pressure, 6% (6%); heart rate, 4% (5%), systolic volume index, 21% (15%); and SpO2, 3% (3%). Significant increases in PaO2 (7% [6%]) and the ratio of PaO2 to the fraction of inspired oxygen were recorded after the recruitment maneuver (P=.016 and P=.014, respectively), but the changes were not clinically significant. CONCLUSIONS: The hemodynamic disturbances associated with the alveolar recruitment maneuver based on sustaining a high end-expiratory pressure and the minor improvement in oxygenation achieved as a result suggest that the routine use of that maneuver in ARDS patients is of questionable value.

Variaciones hemodinámicas inducidas por la realización de unacurva presión–volumen y una maniobra de reclutamiento alveolaren pacientes con síndrome de distrés respiratorio agudo / Hemodynamic variability caused by pressurevolume plotting and alveolar recruitment maneuvers in patients with adult respiratory distress syndrome

OBJETIVOS: La realización de curvas presión-volumen(P-V) y maniobras de reclutamiento (MR) en pacientescon SDRA es una práctica extendida, si bien el mantenimientode una presión intratorácica elevada se asocia aefectos hemodinámicos potencialmente deletéreos. Nuestroobjetivo fue evaluar las alteraciones hemodinámicas y respiratoriasasociadas a la realización de ambas maniobrasy la eficacia a corto plazo de la MR.PACIENTES Y MÉTODOS: Pacientes con criterios de SDRAmonitorizados con un catéter PiCCOTM, en ritmo sinusal yadecuado relleno vascular. Se registraron los valores delíndice cardiaco (IC), presión arterial media (PAM), frecuenciacardiaca (FC), índice de volumen sistólico (IVS) ySpO2 durante la realización de la curva P-V (método quasi-estático) y MR (presión de 40 cmH2O mantenida). Seobtuvieron gasometrías previa a las técnicas y a los 15minutos de su finalización.RESULTADOS: En los 14 pacientes incluidos todos losparámetros estudiados disminuyeron significativamente.La máxima disminución del IC (26 ± 16%), PAM (6 ±6%), FC (4 ± 5%), IVS (21 ± 15%) y SpO2 (3 ± 3%) tuvolugar durante la MR, y se recuperó en menos de 2 minutosen todos los casos. El incremento de la PaO2 (7 ± 6%)y la PaO2/FiO2 (9 ± 8%) tras la MR fue significativo(p = 0,016 y 0,014 respectivamente), pero de escasa relevanciaclínica.CONCLUSIONES: Las alteraciones hemodinámicas asociadasy la escasa eficacia de una maniobra de reclutamientobasada en el mantenimiento de una presión teleinspiratoriaelevada hacen cuestionable su uso rutinario en pacientescon SDRA (AU)

OBJECTIVES: The plotting of pressure-volume curvesand the performance of alveolar recruitment maneuversare common practices in the care of patients with adultrespiratory distress syndrome (ARDS), even thoughpotentially harmful hemodynamic effects are associatedwith sustaining a high intrathoracic pressure. Our aimwas to analyze hemodynamic and ventilatory changesrelated to these 2 maneuvers and to assess the short-termeffectiveness of recruitment.PATIENTS AND METHODS: The patients had ARDS andwere being monitored with a catheter connected to aPiCCO system. All measurements were taken in sinusrhythm and with adequate vascular filling. Values recordedduring plotting of the quasistatic pressure-volume curveand the recruitment maneuver (sustained airway pressureof 40 cm H2O) were the cardiac index, mean arterialpressure, heart rate, systolic volume index, and oxygensaturation (SpO2). Blood gas measurements were recordedbefore the maneuvers and 15 minutes afterwards.RESULTS: All parameters decreased significantly in the14 patients studied. The mean (SD) maximum decreases,from which all patients recovered within 2 minutes, wereas follows: cardiac index, 26% (16%); mean arterialpressure, 6% (6%); heart rate, 4% (5%), systolic volumeindex, 21% (15%); and SpO2, 3% (3%). Significantincreases in PaO2 (7% [6%]) and the ratio of PaO2 to thefraction of inspired oxygen were recorded after therecruitment maneuver (P=.016 and P=.014, respectively),but the changes were not clinically significant.CONCLUSIONS: The hemodynamic disturbancesassociated with the alveolar recruitment maneuver basedon sustaining a high end-expiratory pressure and theminor improvement in oxygenation achieved as a resultsuggest that the routine use of that maneuver in ARDSpatients is of questionable value (AU)

[Bispectral index monitoring during intrahospital transport]. / Monitorización del índice biespectral en el transporte intrahospitalario.

BACKGROUND AND OBJECTIVE: Risk of morbidity and mortality increases for critically ill patients during transfers within the hospital. Such patients often require sedation, and suboptimal sedation is associated with hypertension, tachycardia, and ventilator dyssynchrony. The aim of this study was to assess level of sedation as indicated by monitoring of the bispectral (BIS) index during intrahospital transport of critical patients. PATIENTS AND METHODS: Thirty patients who required transport to the critical care unit within the hospital were studied prospectively. We recorded time in transport, the agent used for sedation and the dosage, the BIS index, mean arterial pressure (MAP), and heart rate before starting transport and upon arrival at the critical care unit. The data were recorded by an observer who was not assigned to patient care. RESULTS: The mean (SD) transport time was 13.9 (4.2) minutes. Midazolam was used in 26 patients and propofol in 4. Ten patients were given a bolus dose of cisatracurium before transfer started. Significant increases were observed in the BIS index (from 47 to 78, (P < .001), MAP (from 73 to 91 mmHg, P < .001), and heart rate (from 72 to 97 beats/min, P < .001) between the moment of starting transport and arrival at the critical care unit. Changes in the BIS index correlated significantly with changes in heart rate (r = 0.418, P = .024) but not with changes in MAP (r = 0.249, P = .19). CONCLUSIONS: Monitoring the BIS index during intrahospital transport of sedated, mechanically ventilated patients may be useful for detecting inadequate sedation.

Monitorización del índice biespectral en el transporte intrahospitalario / Bispectral index monitoring during intrahospital transport

OBJETIVO: El transporte de pacientes críticos supone un incremento de la morbi-mortalidad. Con frecuencia estos pacientes requieren sedación. La sedación insuficiente se acompaña de hipertensión, taquicardia y desadaptación a la ventilación mecánica. El objetivo de este estudio ha sido valorar el grado de sedación durante el transporte intrahospitalario de pacientes críticos monitorizando el índice biespectral (BIS). PACIENTES Y MÉTODO: Se estudiaron prospectivamente 30 pacientes críticos que requirieron transporte intrahospitalario a la Unidad de Críticos. Se recogieron el tiempo de transporte, el fármaco sedante elegido y la dosis empleada, valor BIS, la tensión arterial media (TAM) y la frecuencia cardiaca (FC) antes de iniciar el traslado y a su llegada. Los datos fueron recogidos por un observador no involucrado en el tratamiento de los enfermos. RESULTADOS: El tiempo medio de transporte fue 13,9 ± 4,2 minutos. Se empleó midazolam en 26 casos y en 4 casos propofol. En 10 pacientes se administró un bolo de cisatracurio antes de su traslado. Se observó un incremento significativo del BIS (de 47 a 78, p<0,001), de la TAM (de 73 a 91 mmHg, p<0,001) y de la FC a la llegada a la Unidad de Críticos (de 72 a 97, p<0,001). Las variaciones del BIS mostraron una correlación significativa con las variaciones de la FC (r=0,418, p=0,024), pero no con las de la TAM (r=0,249, p=0,19). CONCLUSIONES: La monitorización del BIS durante el transporte intrahospitalario de pacientes sedados con ventilación mecánica puede ser útil para detectar un grado de sedación superficial

BACKGROUND AND OBJECTIVE: Risk of morbidity and mortality increases for critically ill patients during transfers within the hospital. Such patients often require sedation, and suboptimal sedation is associated with hypertension, tachycardia, and ventilator dyssynchrony. The aim of this study was to assess level of sedation as indicated by monitoring of the bispectral (BIS) index during intrahospital transport of critical patients. PATIENTS AND METHODS: Thirty patients who required transport to the critical care unit within the hospital were studied prospectively. We recorded time in transport, the agent used for sedation and the dosage, the BIS index, mean arterial pressure (MAP), and heart rate before starting transport and upon arrival at the critical care unit. The data were recorded by an observer who was not assigned to patient care. RESULTS: The mean (SD) transport time was 13.9 (4.2) minutes. Midazolam was used in 26 patients and propofol in 4. Ten patients were given a bolus dose of cisatracurium before transfer started. Significant increases were observed in the BIS index (from 47 to 78, (P<.001), MAP (from 73 to 91 mmHg, P<.001), and heart rate (from 72 to 97 beats/min, P<.001) between the moment of starting transport and arrival at the critical care unit. Changes in the BIS index correlated significantly with changes in heart rate (r=0.418, P=.024) but not with changes in MAP (r=0.249, P=.19). CONCLUSIONS: Monitoring the BIS index during intrahospital transport of sedated, mechanically ventilated patients may be useful for detecting inadequate sedation

Monitoring sedation in critically ill patients: bispectral index, Ramsay and observer scales.

BACKGROUND AND OBJECTIVE: Sedation is commonly required by critically ill patients and inadequate sedation may be hazardous. Traditionally, subjective scales have been used for monitoring sedation. Bispectral index has been proposed, although its utility in the intensive care unit is debated. Our aim was to evaluate the depth of sedation in intubated surgical critically ill patients by means of two sedation scales (Ramsay and Observer's Assessment of Alertness and Sedation) and bispectral index. METHODS: Sedation was assessed prospectively in 50 postoperative intubated patients requiring at least 24 h of sedation (35 propofol, 15 midazolam/fentanyl), every 8 h for a 24 -h period. The bispectral index value recorded was the mean value obtained during a 10-min observation period, whenever the quality signal index was above 75% and the electromyographic signal was below 25%. RESULTS: Most of the patients (78%) were oversedated (bispectral index < 60). The three sedation scores (global data) correlated significantly (P < 0.001). This correlation was lost in the midazolam group in which the patients were also significantly more sedated than the propofol group (P = 0.001). The correlation between the bispectral index and the scales in the midazolam group reappeared when the measurements with a Ramsay = 6 or an Observer's Assessment of Alertness and Sedation = 1 were excluded. CONCLUSIONS: Sedation should be monitored routinely in intensive care units. The Ramsay and the Observer's Assessment of Alertness and Sedation scales showed equal efficacy. Bispectral index might prove useful for discriminating between deeper levels of sedation.

Pressure-volume curve variations after a recruitment manoeuvre in acute lung injury/ARDS patients: implications for the understanding of the inflection points of the curve.

BACKGROUND AND OBJECTIVE: Although the pressure-volume (P-V) curve has been proposed in the management of mechanically ventilated patients, its interpretation remains unclear. Our aim has been to study the variations of the P-V curve after a recruitment manoeuvre (RM). Our hypothesis was that the lower inflection point (LIP) represents the presence of compressive atelectases, so it should not change after lung recruitment, while the upper inflection point (UIP) reflects reabsorptive atelectases, and an effective recruitment should result in changes at this level. METHODS: Two P-V curves (quasi-static method) separated by an RM (40 cmH2O, two consecutive manoeuvres) were plotted in 35 postoperative patients with criteria of acute lung injury/acute respiratory distress syndrome (ARDS). LIP, UIP and expiratory inflection point (EIP) were defined as the first point where the curve consistently starts to separate from the line. RESULTS: One to six measurements were obtained per patient (73 procedures). Neither the lower nor the EIPs varied significantly after the RM (P = 0.11 and 0.35, respectively). An UIP was observed in 18 curves (25%) before the RM and disappeared on nine occasions after the recruitment. Similar results were obtained when first measurements only were analysed, and when the cause (pulmonary vs. extrapulmonary), severity of lung injury or duration of mechanical ventilation at first measurement were studied. CONCLUSIONS: An RM does not modify the LIP significantly, but induces the disappearance of the UIP in 50% of the cases in which this point is found.

Adjusting positive end-expiratory pressure and tidal volume in acute respiratory distress syndrome according to the pressure-volume curve.

BACKGROUND: Management of acute respiratory distress syndrome (ARDS) patients implies the selection of the adequate ventilatory parameters, essentially PEEP and tidal volume (Vt), to prevent ventilator-induced lung injury. These parameters should be reset as the lung injury evolves. Among the different methods proposed for the adjustment of the ventilator, the measurement of the P-V curve has emerged as a useful, although debated, tool. Our aim has been to study the relationship between the different inflection points of the P-V curve in ARDS patients, and to assess the changes in the empiric PEEP and Vt (PEEP(emp), V(temp) following its use. METHODS: P-V curves were measured in 27 patients (lung injury score [LIS] >or= 2, 69 measurements) by means of the low-flow continuous inflation method. RESULTS: A lower inflection point (LIP) was found in all patients and, although it correlated with the PEEP(emp), there was only a fair concordance, so the PEEP was modified in 80% of the cases. The expiratory inflection point (EIP) was significantly lower than the LIP (6.3 +/- 1.7 vs. 8.1 +/- 3.2, P = 0.008). An upper inflection point was observed in 16 measurements (23%) and the Vt was reset in 20% of the cases. Both PEEP and Vt were readjusted on 10 occasions (14%). Only the EIP was significantly higher on the first 3 days of mechanical ventilation. The LIS was correlated with all the inflection points. There were no differences for any parameter independent of the cause of the ARDS (pulmonary/extrapulmonary). CONCLUSIONS: The quasi-static measurement of the P-V curve is a simple method, easy to interpret, for objective adjustment of the ventilatory parameters in ARDS patients as the lung injury evolves. The implementation of this strategy may vary the empiric clinical practice. The role of the EIP for the evaluation of the severity of lung injury deserves further investigation.

[Anesthesia in a case of Holt-Oram syndrome]. / Anestesia en un caso de síndrome de Holt-Oram.

A 19-year-old man with Holt-Oram syndrome (HOS) underwent emergency surgical treatment of an occipital abscess. He presented total aplasia of the radius and first and second finger of the left hand, asymmetric thorax and complex cyanotic cardiopathy with double output of the right ventricle that had been treated on several occasions, malpositioning of the large vessels and interventricular conduction. He had been treated with digoxin for episodes of supraventricular tachycardia. After premedication with 0.4 mg of atropine, balanced general anesthesia was induced with etomidate and remifentanil and maintained with O2/air/desflurane and infused remifentanil. The patient remained hemodynamically stable during surgery and tubes were removed in the operating room with no complications. HOS, a hereditary disease characterized by congenital malformations of the upper extremities and the heart, is often associated with rhythm disorders. Problems that may develop in such patients during anesthesia include difficulty catheterizing vessels, difficult orotracheal intubation and ventilation, hemodynamic instability, and the presentation of arrhythmias and cardiac arrest.