Documento práctico del manejo de la hiponatremia en pacientes críticos / Practical document on the management of hyponatremia in critically ill patients

La hiponatremia es el trastorno electrolítico más prevalente en las Unidades de Cuidados Intensivos. Se asocia a un aumento de la morbilidad, mortalidad y estancia hospitalaria. La mayoría de los estudios publicados hasta el momento son observacionales, retrospectivos y no incluyen pacientes críticos, lo que dificulta la extracción de conclusiones sólidas. Además, debido a la escasa evidencia científica de calidad, incluso las recomendaciones realizadas por distintas sociedades científicas recientemente publicadas difieren en aspectos importantes como son el diagnóstico o el tratamiento de la hiponatremia. Los mecanismos etiopatogénicos en los pacientes críticos suelen ser complejos. Sin embargo, hay que profundizar en ellos para llegar al diagnóstico más probable y a la pauta de tratamiento más adecuada. Todo ello, ha motivado la realización de esta revisión práctica sobre aspectos útiles en el abordaje de la hiponatremia en las Unidades de Cuidados intensivos, con el objetivo de homogeneizar el manejo de esta entidad y disponer de un algoritmo diagnóstico a nivel nacional

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient

Practical document on the management of hyponatremia in critically ill patients. / Documento práctico del manejo de la hiponatremia en pacientes críticos.

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

Sedación cooperativa: opción para el manejo de la agitación en el traumatismo craneoencefálico moderado / Cooperative sedation: An option for the management of agitation in moderate traumatic brain injury

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Endocarditis infecciosa en la Unidad de Medicina Intensiva / Infectious endocarditis in the intensive care unit

Objetivo: Conocer las características, evolución y pronóstico de los pacientes con endocarditis infecciosa que requieren tratamiento en la Unidad de Medicina Intensiva. Diseño: Estudio observacional de cohortes prospectivo en pacientes ingresados por endocarditis infecciosa. Ámbito: Hospital Universitario Nuestra Señora de Candelaria, centro con 824 camas y población asignada de 493.145 personas. Pacientes: Todos los pacientes diagnosticados de endocarditis siguiendo los criterios de Duke entre el 1 de enero de 2005 y el 31 de julio de 2011. Variables de interés: Variables demográficas, clínicas, scores de gravedad, hallazgos microbiológicos y ecocardiográficos, mortalidad intrahospitalaria y complicaciones. Resultados: De 102 pacientes diagnosticados de endocarditis, 38 (37%) ingresaron en Medicina Intensiva. Comparándolos con los que no lo hicieron, sufrieron con más frecuencia afectación mitral (OR= 7,13; IC del 95%, 2,12-24; p= 0,002) y embolia cerebral (OR= 3,89; IC del 95%, 1,06-14,3; p= 0,041). La mortalidad fue mayor (42,1 vs 18,8%, p= 0,011), así como la proporción de cirugías urgentes (45,8 vs 5,9%, p<0,001). Resultaron predictores de mortalidad la infección por Estafilococo aureus (OR= 3,49; IC 95%: 1,02-11,93; p=0,046), la insuficiencia cardiaca (OR=4,18; IC 95%: 1,17-14,94; p=0,028), el embolismo cerebral (OR= 8,45; IC 95%: 1,89-37,74; p=0,005) y la puntuación en el score SAPS II al ingreso (OR=1,09; IC 95% 1,04-1,15; p<0,001). Conclusiones: Una elevada proporción de pacientes con endocarditis requieren ingreso en la Unidad de Medicina Intensiva, presentando un pronóstico mucho más desfavorable. La infección por E. aureus, la insuficiencia cardiaca, el embolismo cerebral y la puntuación SAPS II resultan predictores de mortalidad intrahospitalaria (AU)

Objective: To study the characteristics, evolution and prognosis of patients with infectious endocarditis requiring treatment in the Intensive Care Unit. Design: A prospective, observational cohort study of patients admitted due to infectious endocarditis. Setting: Nuestra Señora de Candelaria University Hospital, a third - level center with a recruitment population of 493,145. Patients: All patients consecutively diagnosed with infectious endocarditis in our center according to the Duke criteria, between 1 January 2005 and 31 July 2011. Study variables: Demographic data, clinical severity scores, microbiological and echocardiographic data, hospital mortality and complications. Results: Out of 102 patients diagnosed with endocarditis, 38 (37%) were admitted to Intensive Care. Compared with those patients not admitted to the ICU, these subjects suffered more frequent mitral valve alterations (OR= 7.13; 95%CI: 2.12-24; p= 0.002) and cerebral embolism (OR= 3.89; 95%CI: 1.06-14.3; p= 0.041). In turn, mortality was greater (42.1% vs 18.8%, p= 0.011), as was the proportion of emergency surgeries (45.8% vs 5.9%, p<0.001). The identified mortality predictors were Staphylococcus aureus infection (OR= 3.49; 95%CI 1.02-11.93; p=0.046), heart failure (OR=4.18; 95%CI: 1.17-14.94; p=0.028), cerebral embolism (OR= 8.45; 95%CI: 1.89-37.74; p=0.005) and the SAPS II upon admission (OR=1.09; 95%CI: 1.04-1.15; p<0.001). Conclusions: A large proportion of patients with endocarditis require admission to the Intensive Care Unit, presenting a much poorer prognosis. Staphylococcus aureus infection, heart failure, cerebral embolism and SAPS II scores are independent predictors of hospital mortality (AU)

[Infectious endocarditis in the intensive care unit]. / Endocarditis infecciosa en la Unidad de Medicina Intensiva.

OBJECTIVE: To study the characteristics, evolution and prognosis of patients with infectious endocarditis requiring treatment in the Intensive Care Unit. DESIGN: A prospective, observational cohort study of patients admitted due to infectious endocarditis. SETTING: Nuestra Señora de Candelaria University Hospital, a third - level center with a recruitment population of 493,145. PATIENTS: All patients consecutively diagnosed with infectious endocarditis in our center according to the Duke criteria, between 1 January 2005 and 31 July 2011. STUDY VARIABLES: Demographic data, clinical severity scores, microbiological and echocardiographic data, hospital mortality and complications. RESULTS: Out of 102 patients diagnosed with endocarditis, 38 (37%) were admitted to Intensive Care. Compared with those patients not admitted to the ICU, these subjects suffered more frequent mitral valve alterations (OR= 7.13; 95%CI: 2.12-24; p= 0.002) and cerebral embolism (OR= 3.89; 95%CI: 1.06-14.3; p= 0.041). In turn, mortality was greater (42.1% vs 18.8%, p= 0.011), as was the proportion of emergency surgeries (45.8% vs 5.9%, p<0.001). The identified mortality predictors were Staphylococcus aureus infection (OR= 3.49; 95%CI 1.02-11.93; p=0.046), heart failure (OR=4.18; 95%CI: 1.17-14.94; p=0.028), cerebral embolism (OR= 8.45; 95%CI: 1.89-37.74; p=0.005) and the SAPS II upon admission (OR=1.09; 95%CI: 1.04-1.15; p<0.001). CONCLUSIONS: A large proportion of patients with endocarditis require admission to the Intensive Care Unit, presenting a much poorer prognosis. Staphylococcus aureus infection, heart failure, cerebral embolism and SAPS II scores are independent predictors of hospital mortality.

Avances en el traumatismo craneoencefálico / Advances in the management of head injury

El traumatismo craneoencefálico (TCE) produce un gran impacto en nuestra sociedad al ser la primera causa de muerte en personas menores de 45 años y la tercera a cualquier edad, a lo que hay que añadir el problema familiar, el social y el financiero de los que sobreviven con secuelas. Dado que la mayoría de los cambios fisiopatológicos en el metabolismo y en el flujo sanguíneo cerebral ocurren en las primeras horas del traumatismo, el manejo inicial de estos pacientes por parte de los servicios de emergencias y en la sala de urgencias de los hospitales juega un papel fundamental en su pronóstico final. Si bien no podemos evitar en ese momento la lesión primaria, sí podemos actuar limitando su progresión mediante la minimización del daño cerebral secundario. Desde el primer contacto con el paciente y tras las medidas básicas de reanimación, el objetivo fundamental debe ser mantener una estabilidad global que evite principalmente la hipotensión y la hipoxia, que son factores pronósticos independientes de morbimortalidad. Además, los pacientes con traumatismo craneal grave deben ser trasladados en condiciones estables a un hospital de tercer nivel que disponga de servicio de neurocirugía y medicina intensiva con técnicas de neuromonitorización, como la presión intracraneal y la oxigenación cerebral. En esta revisión haremos varios apartados que son básicos para el actual manejo del TCE: inicialmente describiremos los conceptos fisiopatológicos en el traumatismo que inciden sobre el flujo sanguíneo cerebral, la presión intracraneal y el metabolismo cerebral, así como los tipos de lesiones primarias y secundarias; en segundo lugar, y de forma más extensa, la evaluación y el manejo pre-hospitalario, en la sala de urgencias y, por último, el tratamiento en la unidad de medicina intensiva basado en técnicas de neuromonitorización multimodal (AU)

Head injuries have a profound societal impact given that they are the leading cause of death in persons under 45 years of age and the third leading cause overall. To this, we must add the family, social, and financial burdens of survivors who suffersequelae. Most pathophysiologic changes in cerebral metabolism and blood flow occur in the first few hours after injury. Early management by emergency services and in hospital emergency departments therefore plays a key role in determining prognosis. Although the primary injury cannot be undone, we can limit its progression by minimizing secondary brain damage. From the moment of first response to the patient, once basic resuscitation measures have been taken, the main goal should be to stabilize the patient, especially preventing hypotension and hypoxia, which are independent risk factors for morbidity and mortality. Patients with severe head injury must be transported in stable condition to a tertiary care hospital with a neurosurgery department and an intensive care unit that can monitor such neurologic variables as intracranial pressure and cerebral oxygenation. This review of head injury management addresses 2 aspects that are essential for treatment. We first describe pathophysiologic concepts that influence cerebral blood flow and metabolism and intracranial pressure, and we also cover types of primary and secondary injuries. We then discuss evaluation and management more thoroughly, including measures in prehospital and emergency department settings, as well as intensive care unit treatment involving multimodal neurologic monitoring techniques (AU)

Elevación de la cabecera de la cama en el traumatismo craneoencefálico grave / Elevation of the bed headboard in severe cranioencephalic trauma

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[External ventricular drainage in complete infarction of the medial cerebral artery]. / Drenaje ventricular externo en el infarto completo de la arteria cerebral media.

INTRODUCTION: Increased intracranial pressure (ICP) due to complete middle cerebral artery territory infarction does not respond to medical treatment and is often followed by transtentorial herniation and death. Some authors have reported good outcome after performing decompressive hemicraniectomy in this condition. The potential clinical benefit of intracranial pressure reduction by means of an external ventriculostomy in such cases is unknown. CASE REPORT: The present paper discusses the case of a 33 year old female who suffered a massive infarction of the territory of the right middle cerebral artery with transtentorial herniation and left lateral ventricular dilation who rapidly improved after performing external ventriculostomy without hemicraniectomy. The brain tissue partial oxygen pressure (PtiO2) was monitored in the left frontal lobe and a fair correlation with clinical events was found. CONCLUSIONS: External ventricular drainage without hemicraniectomy could be lifesaving in some case of massive ( malignant ) hemispheric infarction and more studies on this therapeutic approach would be needed. Monitoring PtiO2 in these patients would be useful in adopting therapeutic decisions.

Drenaje ventricular externo en el infarto completo de la arteria cerebral media / External ventricular drainage in complete infarction of the medial cerebral artery

Introducción. La hipertensión intracraneal grave debida al infarto de todo el territorio de la arteria cerebral media responde mal al tratamiento médico y, a menudo, le sigue una herniación transtentorial y la muerte. Recientemente se han publicado buenos resultados tras la práctica de una hemicraniectomía descompresiva en estos casos. Caso clínico. Comunicamos una paciente de 33 años que sufrió un infarto masivo de la arteria cerebral media derecha, con herniación transtentorial y dilatación del ventrículo lateral izquierdo, que respondió bien a la realización de una ventriculostomía externa sin hemicraniectomía. Se monitorizó la presión parcial cerebral de oxígeno (PtiO2) en el lóbulo frontal izquierdo y se observó una estrecha relación con los eventos clínicos. Conclusiones. El drenaje ventricular externo sin craniectomía fue, aparentemente, una medida terapéutica útil en nuestra paciente con un infarto `maligno' hemisférico. Son necesarios más estudios en este sentido. La monitorización de la PtiO2 en estos casos ayudaría a valorar y optimizar las decisiones terapéuticas (AU)

Introduction. Increased intracranial pressure (ICP) due to complete middle cerebral artery territory infarction does not respond to medical treatment and is often followed by transtentorial herniation and death. Some authors have reported good outcome after performing decompressive hemicraniectomy in this condition. The potential clinical benefit of intracranial pressure reduction by means of an external ventriculostomy in such cases is unknown. Case report. The present paper discusses the case of a 33-year-old female who suffered a massive infarction of the territory of the right middle cerebral artery with transtentorial herniation and left lateral ventricular dilation who rapidly improved after performing external ventriculostomy without hemicraniectomy. The brain tissue partial oxygen pressure (PtiO2) was monitored in the left frontal lobe and a fair correlation with clinical events was found. Conclusions. External ventricular drainage without hemicraniectomy could be lifesaving in some case of massive (‘malignant’) hemispheric infarction and more studies on this therapeutic approach would be needed. Monitoring PtiO2 in these patients would be useful in adopting therapeutic decisions (AU)