Trombectomía mecánica en el ictus isquémico agudo, conociendo nuestros resultados / Mechanical thrombectomy in acute ischemic stroke, knowing our results

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Mortality prediction using TRISS methodology in the Spanish ICU Trauma Registry (RETRAUCI).

OBJECTIVES: To validate Trauma and Injury Severity Score (TRISS) methodology as an auditing tool in the Spanish ICU Trauma Registry (RETRAUCI). DESIGN: A prospective, multicenter registry evaluation was carried out. SETTING: Thirteen Spanish Intensive Care Units (ICUs). PATIENTS: Individuals with traumatic disease and available data admitted to the participating ICUs. INTERVENTIONS: Predicted mortality using TRISS methodology was compared with that observed in the pilot phase of the RETRAUCI from November 2012 to January 2015. Discrimination was evaluated using receiver operating characteristic (ROC) curves and the corresponding areas under the curves (AUCs) (95% CI), with calibration using the Hosmer-Lemeshow (HL) goodness-of-fit test. A value of p<0.05 was considered significant. MAIN VARIABLES OF INTEREST: Predicted and observed mortality. RESULTS: A total of 1405 patients were analyzed. The observed mortality rate was 18% (253 patients), while the predicted mortality rate was 16.9%. The area under the ROC curve was 0.889 (95% CI: 0.867-0.911). Patients with blunt trauma (n=1305) had an area under the ROC curve of 0.887 (95% CI: 0.864-0.910), and those with penetrating trauma (n=100) presented an area under the curve of 0.919 (95% CI: 0.859-0.979). In the global sample, the HL test yielded a value of 25.38 (p=0.001): 27.35 (p<0.0001) in blunt trauma and 5.91 (p=0.658) in penetrating trauma. TRISS methodology underestimated mortality in patients with low predicted mortality and overestimated mortality in patients with high predicted mortality. CONCLUSIONS: TRISS methodology in the evaluation of severe trauma in Spanish ICUs showed good discrimination, with inadequate calibration - particularly in blunt trauma.

Efficacy of an extravascular lung water-driven negative fluid balance protocol

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI > 9 ml/kg. The protocol dictates a negative fluid balance between 500 and 1500 ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210 mmHg (IQR 164, 248) (p < 0.001), and EVLWI decreased from 14 (11, 18) to 10 ml/kg (8, 14) (p < 0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10 ml/kg (8, 14) at the end of the protocol (p = 0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216 mmHg (IQR 137, 260) at the beginning versus 205 mmHg (IQR 99,257) at the end of the study (p = 0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group

OBJETIVO: Analizar la eficacia del balance hídrico negativo en pacientes hipoxémicos y con Agua Pulmonar Extravascular Indexada (EVLWI) elevada. Diseño: Estudio retrospectivo y observacional. ÁMBITO: Unidad de Cuidados Intensivos del Hospital Virgen de las Nieves. Participantes: 44 pacientes. Intervenciones: Se analizó la base de datos de pacientes hipoxémicos durante 11 meses consecutivos. Se incluyeron los pacientes hipoxémicos, hemodinámicamente estables y con EVLWI > 9 ml/kg. El protocolo dicta un balance hídrico negativo entre 500 y 1500 ml/día. Se analizó el impacto de esta estrategia de balance negativo en la función respiratoria, hemodinámica y renal. Variables de interés principales: Datos demográficos, escalas de gravedad y datos clínicos hemodinámicos, respiratorios, metabólicos y de función renal. RESULTADOS: 33 pacientes lograron balance hídrico negativo (Grupo BHN) y 11 tuvieron balance hídrico positivo (Grupo BHP). En el grupo BHN la PaO2/FiO2 pasó de 145 (IQR 106,200) a 210 (IQR 164, 248) mmHg (p < 0.001), el EVLWI descendió de 14 (11, 18) a 10 (8, 14) ml/kg (p < 0.001). En el grupo BHP, el EVLWI también descendió de 11(10, 14) a 10 (8, 14) ml/kg al final del protocolo (p = 0.004); en este último grupo no hubo cambios estadísticamente significativos en la oxigenación y la PaO2/FiO2 pasó de 216 (IQR 137, 260) a 205 (IQR 99, 257) mmHg (p = 0.08). CONCLUSIÓN: Tres de cada cuatro pacientes hipoxémicos y con EVLWI elevados toleraron el protocolo; en ellos, la mejora de diversos parámetros analizados fue mayor y más rápida que en los pacientes que no hicieron balance negativo. Los pacientes que no toleraron el protocolo fueron los más graves aunque se necesitaría una muestra mayor para determinar las características específicas en estos

Efficacy of an extravascular lung water-driven negative fluid balance protocol.

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI>9ml/kg. The protocol dictates a negative fluid balance between 500 and 1500ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210mmHg (IQR 164, 248) (p<0.001), and EVLWI decreased from 14 (11, 18) to 10ml/kg (8, 14) (p<0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10ml/kg (8, 14) at the end of the protocol (p=0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216mmHg (IQR 137, 260) at the beginning versus 205mmHg (IQR 99,257) at the end of the study (p=0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group.

Quality of trauma care and trauma registries.

Traumatic disease is a major public health concern. Monitoring the quality of services provided is essential for the maintenance and improvement thereof. Assessing and monitoring the quality of care in trauma patient through quality indicators would allow identifying opportunities for improvement whose implementation would improve outcomes in hospital mortality, functional outcomes and quality of life of survivors. Many quality indicators have been used in this condition, although very few ones have a solid level of scientific evidence to recommend their routine use. The information contained in the trauma registries, spread around the world in recent decades, is essential to know the current health care reality, identify opportunities for improvement and contribute to the clinical and epidemiological research.

Código alfa. Inicio de un nuevo programa de donación en asistolia / Alpha code. The start of a new non-heart beating donor program

Objetivo: Presentar resultados iniciales de un programa de donación en asistolia (DA) en unaciudad de menos de 500.000 habitantes. Diseño: Estudio observacional prospectivo durante 2010 y 2011.Ámbito: Hospital Virgen de las Nieves y Área Metropolitana de Granada. Población: DA y donantes en muerte encefálica (DME) de la provincia de Granada en 2010 y2011.Variables de interés: Características de los DA, tiempos extrahospitalarios e intrahospitalarios, negativas familiares y judiciales, métodos de preservación, procedimiento de información a familiares. Órganos: causas de no validez, extraídos y trasplantados. Receptores: sesiones de hemodiálisis y creatinina al alta. DME: número de donantes reales (DR) y de trasplantes renales. Resultados: En ME hubo 102 DR y se realizaron 104 trasplantes renales. Se han registrado en asistolia 22 donantes potenciales (DP), 21 donantes elegibles (DE), 20 DR y 13 donantes utilizados(DU). Edad media de los DR: 50 años (rango 33-62), 16 hombres y 4 mujeres. Se han realizado21 trasplantes renales y 2 hepáticos de DA. Las causas de no validez son múltiples. Número medio de sesiones de hemodiálisis postrasplante: 1,4 (rango 0-6). Estancia hospitalaria media:25 días (rango 14-41). Creatinina media al alta: 3,4 mg/dL (rango 1,5-6,4). Ninguna negativa judicial y una negativa familiar. Se describen los métodos de preservación y el procedimiento de información a familiares. Conclusiones: Los resultados iniciales apoyan el desarrollo de programas de DA en ciudades de menos de 500.000 habitantes. La DA ha supuesto en 2011 el 20,19% de los trasplantes renales y el 19,6% de los donantes de órganos de la provincia de Granada (AU)

Objective: To present the preliminary results of a non-heart beating donor (NHBD) program in a city of under 500,000 inhabitants. Design: A prospective observational study was conducted between 2010 and 2011.Setting: Virgin de las Nieves Hospital and metropolitan area of Granada (Spain).Population: NHBD and brain dead donors (BDD) in the province of Granada during 2010 and2011.Study variables: Characteristics of NHBD, out- and in-hospital times, family and legal refusals, preservation methods, and family information procedure. Organs: reasons for organnon-validness, and harvested and transplanted organs. Recipients: hemodialysis sessions and creatinine at discharge. BDD: number of real donors (RD) and of kidney transplants. Results: Among the BDD there were 102 RD and 104 kidney transplants were carried out. In systole, 22 potential donors, 21 eligible donors, 20 RD and 13 used donors were registered. The mean age among the RD was 50 years (range 33-62)(16 males and 4 females). Twenty-onekidney and two liver transplants from NHBD were performed. There were a number of reasons for organ non-validness. The mean number of post-transplantation hemodialysis sessions was1.4 (range 0-6). The mean hospital stay was 25 days (range 14-41), and the mean creatinine concentration at discharge was 3.4 mg/dl (range 1.5-6.4). There was one family rejection and no legal (court-ruled) rejections. The preservation methods and family information procedure are described. Conclusions: The preliminary results support the development of NHBD programs in cities with under 500,000 inhabitants. In 2011, NHBD accounted for 20.19% of the kidney transplants and19.60% of the global organ donations in the province of Granada (AU)

El consumo de alcohol y/o drogas favorece la reincidencia en el traumatismo y reduce el período sin traumatismos / Alcohol and/or drug abuse favors trauma recurrence and reduces the trauma-free period

Objetivo Nuestro objetivo ha sido determinar la influencia del consumo de alcohol y/o drogas en la reincidencia de pacientes traumatizados y, en pacientes no reincidentes, analizar el papel de estas sustancias en el tiempo de aparición del primer episodio de traumatismo. Diseño Estudio observacional prospectivo. Ámbito Unidad de cuidados intensivos (UCI) de un hospital terciario. Pacientes traumatizados ingresados en UCI. Intervención Ninguna. Variables principales La reincidencia en el traumatismo se definió por antecedentes de traumatismo previo que requiriera atención médica. Se ha determinado la presencia de alcohol y otras drogas de abuso al ingreso tras un traumatismo grave. Resultados De los 166 pacientes con traumatismo ingresados en la UCI durante el período de estudio, se incluyeron 102 (87 hombres). Se detectó alguna sustancia en 51 pacientes (50%), alcohol (39%), cannabis (12%) y cocaína (7%). De los 102 pacientes, 42 eran reincidentes, de los cuales 32 (76%) dieron positivo a alguna sustancia y solo en 10 se obtuvieron resultados negativos (p<0,001). De los 60 pacientes no reincidentes, 19 (32%) dieron resultados positivos a alguna sustancia, estos últimos eran significativamente más jóvenes (34,3±9 años) que los 41 con resultados negativos (48±23 años) (p<0,001).Conclusión El consumo de alcohol y/o drogas aumenta la probabilidad de reincidencia en el traumatismo y adelanta en casi 15 años la presentación del primer traumatismo (AU)

Aim A study is made of the influence of alcohol and/or drug abuse upon traumatism o recurrence, with an analysis of the influence of such abuse upon the time to appearance of first injury in patients without antecedents of trauma. Design A prospective observational study was made. Setting Trauma patients admitted to the Intensive care Unit (ICU) of a University Hospital. Patients Trauma patients admitted to the ICU. Intervention None. Main measurements Trauma recurrence was defined by a history of previous trauma requiring medical care. The presence of alcohol and other drugs of abuse were determined upon admission after severe trauma. Results Out of the 166 trauma patients admitted to the ICU during the study period, 102 (87 males) were included in the study. Some substance was detected in 51 patients (50%), most frequently in the males (48/87, p<0.02). The most frequently detected substance was alcohol (39%), followed by cannabis (12%) and cocaine (7%), while more than one substance was found in 10 patients (9.8%). Of the 102 patients, 42 were recurrent trauma cases, and 32 (76%) of them were substance-positive, while only 10 were substance-negative (p<0.001). Of the 60 patients without antecedents of trauma, 19 (32%) were substance-positive, and these were significantly younger (34.3±9 years) than the 41 subjects who were substance-negative (48±23 years) (p<0.001).Conclusion Alcohol and/or drug abuse increases the likelihood of recurrent trauma and may shorten the mean trauma-free period among patients without a history of trauma by almost 15 years (AU)

Alpha code. The start of a new non-heart beating donor program.

OBJECTIVE: To present the preliminary results of a non-heart beating donor (NHBD) program in a city of under 500,000 inhabitants. DESIGN: A prospective observational study was conducted between 2010 and 2011. SETTING: Virgen de las Nieves Hospital and metropolitan area of Granada (Spain). POPULATION: NHBD and brain dead donors (BDD) in the province of Granada during 2010 and 2011. STUDY VARIABLES: Characteristics of NHBD, out- and in-hospital times, family and legal refusals, preservation methods, and family information procedure. Organs: reasons for organ non-validness, and harvested and transplanted organs. Recipients: hemodialysis sessions and creatinine at discharge. BDD: number of real donors (RD) and of kidney transplants. RESULTS: Among the BDD there were 102 RD and 104 kidney transplants were carried out. In asystole, 22 potential donors, 21 eligible donors, 20 RD and 13 used donors were registered. The mean age among the RD was 50 years (range 33-62)(16 males and 4 females). Twenty-one kidney and two liver transplants from NHBD were performed. There were a number of reasons for organ non-validness. The mean number of post-transplantation hemodialysis sessions was 1.4 (range 0-6). The mean hospital stay was 25 days (range 14-41), and the mean creatinine concentration at discharge was 3.4mg/dl (range 1.5-6.4). There was one family rejection and no legal (court-ruled) rejections. The preservation methods and family information procedure are described. CONCLUSIONS: The preliminary results support the development of NHBD programs in cities with under 500,000 inhabitants. In 2011, NHBD accounted for 20.19% of the kidney transplants and 19.60% of the global organ donations in the province of Granada.

Alcohol and/or drug abuse favors trauma recurrence and reduces the trauma-free period.

AIM: A study is made of the influence of alcohol and/or drug abuse upon traumatismo recurrence, with an analysis of the influence of such abuse upon the time to appearance of first injury in patients without antecedents of trauma. DESIGN: A prospective observational study was made. SETTING: Trauma patients admitted to the Intensive care Unit (ICU) of a University Hospital. PATIENTS: Trauma patients admitted to the ICU. INTERVENTION: None. MAIN MEASUREMENTS: Trauma recurrence was defined by a history of previous trauma requiring medical care. The presence of alcohol and other drugs of abuse were determined upon admission after severe trauma. RESULTS: Out of the 166 trauma patients admitted to the ICU during the study period, 102 (87 males) were included in the study. Some substance was detected in 51 patients (50%), most frequently in the males (48/87, p<0.02). The most frequently detected substance was alcohol (39%), followed by cannabis (12%) and cocaine (7%), while more than one substance was found in 10 patients (9.8%). Of the 102 patients, 42 were recurrent trauma cases, and 32 (76%) of them were substance-positive, while only 10 were substance-negative (p<0.001). Of the 60 patients without antecedents of trauma, 19 (32%) were substance-positive, and these were significantly younger (34.3±9 years) than the 41 subjects who were substance-negative (48±23 years) (p<0.001). CONCLUSION: Alcohol and/or drug abuse increases the likelihood of recurrent trauma and may shorten the mean trauma-free period among patients without a history of trauma by almost 15 years.

Manejo inicial del ictus isquémico agudo / No disponible

No disponible

[General management in intensive care of patient with spontaneous subarachnoid hemorrhage]. / Manejo general en Cuidados Intensivos del paciente con hemorragia subaracnoidea espontánea.

Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency and often a neurologic catastrophe. Nontraumatic subarachnoid hemorrhage is characterized by the extravasation of blood into the spaces covering the central nervous system. The leading cause of SAH is rupture of an intracranial aneurysm, which accounts for about 80-85% of cases. Mortality and morbidity can be reduced if SAH is treated urgently. Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH; computered tomography (CT) scanning is mandatory in all the patients with symp toms that are suggestive of SAH. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. Diagnosing SAH can be challenging and treatment is complex, sophisticated and multidisciplinary. Reble eding is the most imminent danger, which must be prevented by endovascular occlusion with detachable coils (coiling) or by surgical clipping of the aneurysm; the risk of delayed cerebral ischemia is reduced with nimodipine and avoiding hypovolemia; hydrocephalus can be treated by ventricular drainage. Intensive care plays a more important role in the management of SAH than in any other neurological disorder. Excellence in neurologic diagnosis, in operative neurosurgery or neuroradiologic procedures must be accompanied by excellence in Intensive Care. This review emphasizes treatment in the Intensive Care Unit, surgical and endovascular therapeutic options and the current state of treatment of major complications such as rebleeding, cerebral vasospasm and acute hydrocephalus.

[Incidence of the consumption of toxic substances in severe trauma patients]. / Incidencia del consumo de tóxicos en pacientes con traumatismos graves.

OBJECTIVE: To determine the incidence of the detection of abuse drugs in severe trauma patients DESIGN: Prospective observational study conducted from July 2004 to January 2006. SETTING: Neurotrauma intensive care unit of a reference tertiary university hospital. PATIENTS: Trauma patients who require admission to ICU during the study period. INTERVENTIONS: Determination of alcohol in blood and of toxics (cocaine, cannabis, amphetamines and other substances) in urine. RESULTS: Toxicological analysis was performed in 196 of the 288 severe trauma patients admitted during the study period. The most frequently detected cause of the trauma was traffic accident (69%). The most frequently detected substance was cannabis (22.4%), followed by alcohol (17.3%) and cocaine (12.8%). Cannabis was detected in 26.1% of under-45-yr-old patients versus 9.3% of older patients (p < 0.05), and cocaine in 16.3% vs. 0% in over-45-yr-olds (p < 0.001). Some substance of abuse was detected in 45% of under-45-yr-olds versus 23% of older patients (p < 0.05). CONCLUSION: The high proportion of positive results to toxic substances in severely traumatized patients suggests that the epidemiological environment for these patients is of great concern. These data may be of interest for the design of future prevention campaign.

Incidencia del consumo de tóxicos en pacientes con traumatismos graves / Incidence of the consumption of toxic substances in severe trauma patients

Objetivo. Determinar la incidencia de detecciónde drogas de abuso en pacientes con traumatismograve.Diseño. Estudio observacional prospectivo,rea lizado entre julio de 2004 y enero de 2006.Ámbito. Unidad de Cuidados Intensivos (UCI)neurotraumatológica de un hospital de tercer nivel.Pacientes. Pacientes con traumatismos queprecisaron el ingreso en la UCI durante el períodode estudio.Intervenciones. Análisis de alcoholemia y de tóxicos(cocaína, cannabis, anfetaminas y otras) enorina.Resultados. Se obtuvo una muestra para análisisde tóxicos en 196 pacientes de los 288 ingresadospor traumatismo grave. La causa más frecuentedel traumatismo fue el accidente detráfico, con un 69%. El tóxico más frecuentementeencontrado fue el cannabis (22,4%), seguidodel alcohol (17,3%) y la cocaína (12,8%). En menoresde 45 años, el cannabis fue detectado en el26,1% frente al 9,3% en mayores de 45 años (p < 0,05)y la cocaína en un 16,3% frente al 0% (p < 0,001).En menores de 45 años fue detectada la presenciade algún tóxico en el 45% frente al 23% en mayoresde 45 años (p < 0,05).Conclusión. La alta proporción de resultadospositivos a tóxicos en pacientes con traumatismosgraves sugiere que el ambiente epidemiológicoen que se mueven estos pacientes es muy preocupante. Estos datos deberían tener importancia para diseñar futuras campañas de prevención

Objective. To determine the incidence of thedetection of abuse drugs in severe trauma patientsDesign. Prospective observational study conductedfrom July 2004 to January 2006.Setting. Neurotrauma intensive care unit of areference tertiary university hospital.Patients. Trauma patients who require admissionto ICU during the study period.Interventions. Determination of alcohol in bloodand of toxics (cocaine, cannabis, amphetaminesand other substances) in urine.Results. Toxicological analysis was performedin 196 of the 288 severe trauma patients admittedduring the study period. The most frequently detectedcause of the trauma was traffic accident(69%). The most frequently detected substancewas cannabis (22.4%), followed by alcohol(17.3%) and cocaine (12.8%). Cannabis was detectedin 26.1% of under-45-yr-old patients versus9.3% of older patients (p < 0.05), and cocainein 16.3% vs. 0% in over-45-yr-olds (p < 0.001).Some substance of abuse was detected in 45% ofunder-45-yr-olds versus 23% of older patients (p< 0.05).Conclusion. The high proportion of positive resultsto toxic substances in severely traumatizedpatients suggests that the epidemiological environmentfor these patients is of great concern These data may be of interest for the design of future prevention campaign

[Prognostic capacity of brain herniation signs in patients with structural neurological injury]. / Capacidad pronóstica de los signos de herniación cerebral en pacientes con afectación neurológica estructural.

OBJECTIVE: To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement. DESIGN: Prospective cohort study. SETTING: Trauma ICU in university hospital. PATIENTS: One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke. MAIN VARIABLES OF INTEREST: Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores. RESULTS: Mean age was 47.8 +/- 19.4 years; APACHE II, 17.1 +/- 7.2 points; SAPS II, 43.7 +/- 17.7 points; and APACHE III, 55.8 +/- 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 +/- 5.5 vs. 1.6 +/- 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25). CONCLUSIONS: In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes.

Capacidad pronóstica de los signos de herniación cerebral en pacientes con afectación neurológica estructural / Prognostic capacity of brain herniation signs in patients with structural neurological injury

Objetivo. Analizar en los pacientes con afectación neurológica estructural si los sistemas de predicción de mortalidad habitualmente usados (APACHE y SAPS) pueden ser complementados con los hallazgos de herniación cerebral encontrados en la tomografía computarizada (TC) craneal. Diseño. Estudio prospectivo de cohortes. Ámbito. Unidad de Cuidados Intensivos (UCI) de Traumatología de un hospital universitario. Pacientes. Ciento cincuenta y cinco pacientes ingresados en UCI durante el 2003 con traumatismo craneoencefálico (TCE) o accidente cerebrovascular agudo (ACVA). Variables de interés principales. Se recogió información sobre la edad, el diagnóstico, la mortalidad, los hallazgos en la TC craneal al ingreso, APACHE II, APACHE III y SAPS II. Resultados. La edad fue de 47,8 ± 19,4 años, el APACHE II 17,1 ± 7,2 puntos, el SAPS II 43,7 ± 17,7 puntos y el APACHE III de 55,8 ± 29,7 puntos. La mortalidad hospitalaria fue del 36% y la predicha por el SAPS II fue del 38%, por el APACHE II 30% y por el APACHE III 36%. Los 56 pacientes que fallecieron presentaban mayor desviación de la línea media en la TC craneal que los supervivientes: 4,2 ± 5,5 frente a 1,7 ± 3,2 mm (p = 0,002) y mayor gravedad evaluada con el SAPS II, APACHE II y APACHE III. La mortalidad fue significativamente mayor en los pacientes con herniación subfalcial (61% frente a 30%, p < 0,001). En el análisis multivariante con regresión logística se encontró que la mortalidad hospitalaria se asoció con la probabilidad de fallecer según el APACHE III (OR 1,07; IC 95%: 1,05-1,09) y con la presencia de herniación subfalcial (OR 3,15; IC 95%: 1,07-9,25). Conclusiones. En los pacientes críticos con afectación estructural neurológica, la presencia de signos de herniación subfalcial en la TC craneal complementan la información pronóstica de los índices de gravedad normalmente utilizados

Objective. To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement. Design. Prospective cohort study. Setting. Trauma ICU in university hospital. Patients. One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke. Main variables of interest. Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores. Results. Mean age was 47.8 ± 19.4 years; APACHE II, 17.1 ± 7.2 points; SAPS II, 43.7 ± 17.7 points; and APACHE III, 55.8 ± 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 ± 5.5 vs. 1.6 ± 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25). Conclusions. In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes

Valoración clínica de la lesión pulmonar aguda / Clinical assessment of acute lung injury

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