Inferior Vena Cava Thrombosis Related to Hypothermia Catheter: Report of 20 Consecutive Cases.

BACKGROUND: Temperature management using endovascular catheters is an established therapy in neurointensive care. Nonetheless, several case series have reported a high rate of thrombosis related to the use of endovascular hypothermia catheters. METHODS: As a result of a pulmonary embolism that developed in a patient after removing an inferior vena cava hypothermia catheter, we designed a clinical protocol for managing and removing these devices. First, an invasive cavography was performed before the removal of the catheter. If there was a thrombus, a cava vein filter was inserted through jugular access. After that, the catheter was removed. RESULTS: The venography found inferior vena cava thrombi in 18 of 20 consecutive patients. A concomitant ultrasonography study showed vena cava thrombosis in only three patients. A vena cava filter was inserted in all patients where thrombi were found, without any significant complication. Anticoagulation was started in all patients. No symptomatic pulmonary embolism was diagnosed until the time of discharge. CONCLUSIONS: The frequency of thrombosis related to temperature management catheters is extremely high (90 %). Furthermore, ultrasonography has a very low sensibility to detect cava vein thrombosis (16.7 %). The real meaning of our findings is unknown, but other temperature control systems could be a safer option. More studies are needed to confirm our findings.

[Community acquired infections with methicillin resistant strains of Staphylococcus aureus: report of five cases]. / Staphylococcus aureus comunitario resistente a cloxacilina: Comunicación de los primeros cinco casos descritos en Chile.

Community acquired infections with methicillin resistant strains of Staphylococcus aureus (MRSA) infections have a more aggressive clinical course and involve mostly skin and lungs. These infections appear as outbreaks among prisoners, sportsmen, men having sex with men and military personnel. The higher aggressiveness of these strains is due to the production of several toxins, mainly Panton- Valentine leukocidine. The detection of the gene that codes for this toxin is a distinctive feature of these strains. We report five patients with community acquired MRSA infections. The clinical presentation was a skin infection in all. One patient had a pleuropneumonia in addition. Apart for resistance to beta-lactam antimicrobials, the strains were resistant to erythromycin and ciprofloxacin. Patients were treated with vancomycin, clotrimoxazole or intravenous clindamycin with a good evolution. An epidemiological surveillance for community acquired MRSA strain infections should be started and measures to adequately treat infected patients and avoid dissemination should be implemented.

Staphylococcus aureus comunitario resistente a cloxacilina: comunicación de los primeros cinco casos descritos en Chile / Community acquired infections with methicillin resistant strains of Staphylococcus aureus: report of five cases

Community acquired infections with methicillin resistant strains of Staphylococcus aureus (MRSA) infections have a more aggresive clinical course and involve mostly skin and lungs. These infections appear as outbreaks among prisoners, sportsmen, men having sex with men and military personnel. The higher aggressiveness of these strains is due to the production of several toxins, mainly Panton- Valentine leukocidine. The detection of the gene that codes for this toxin is a distinctive feature of these strains. We report five patients with community acquired MRSA infections. The clinical presentation was a skin infection in all. One patient had a pleuropneumonia in addition. Apart for resistance to beta-lactam antimicrobials, the strains were resistant to erythromycin and ciprofloxacin. Patients were treated with vancomycin, clotrimoxazole or intravenous clindamycin with a good evolution. An epidemiológical surveillance for community acquired MRSA strain infections should be started and measures to adequately treat infected patients and avoid dissemination should be implemented.

[Mechanical ventilatory parameters guided by the low flow pressure-volume curve in patients with acute lung injury/acute respiratory distress syndrome]. / Ajuste a la ventilación mecánica guiado por curvas presión-volumen de flujo lento en pacientes con síndrome de distress respiratorio agudo e injuria pulmonar aguda.

BACKGROUND: Mechanical ventilation may contribute to lung injury and then enhance systemic inflammation. Optimal ventilatory parameters such as tidal volume (VT) and positive end expiratory pressure (PEEP) can be determined using different methods. Low flow pressure volume (P/V-LF) curve is a useful tool to assess the respiratory system mechanics and set ventilatory parameters. AIM: To set VT and PEEP according P/V-LF curve analysis and evaluate its effects on gas exchange and hemodynamic parameters. MATERIALS AND METHODS: Twenty seven patients underwent P/V-LF within the first 72 hours of acute lung injury/acute respiratory distress syndrome (ALI/ARDS). P/V-LF curves were obtained from the ventilator and both lower and upper inflexion points determined. Gas exchange and hemodynamic parameters were measured before and after modifying ventilator settings guided by P/V-LF curves. RESULTS: Ventilatory parameters set according P/V-LF curve, led to a rise of PEEP and reduction of VT: 11.6+/-2.8 to 14.1+/-2.1 cm H2O, and 9.7+/-2.4 to 8.8+/-2.2 mL/kg (p<0.01). Arterial to inspired oxygen fraction ratio increased from 158.0+/-66 to 188.5+/-68.5 (p<0.01), and oxygenation index was reduced, 13.7+/-8.2 to 12.3+/-7.2 (p<0.05). Cardiac output and oxygen delivery index (IDO2) were not modified. Demographic data, gas exchange improvement and respiratory system mechanics showed no significant difference between patients with extra-pulmonary and pulmonary ALI/ARDS. There was no evidence of significant adverse events related with this technique. CONCLUSION: P/V-LF curves information allowed us to adjust ventilatory parameters and optimize gas exchange without detrimental effects on oxygen delivery in mechanically ventilated ALI/ARDS patients.

[Addition of an arterio-venous shunt during veno-arterial extracorporeal life support in a patient with Hantavirus pulmonary syndrome]. / Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus. Caso clínico.

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

[Intrathoracic blood volume versus pulmonary artery occlusion pressure as estimators of cardiac preload in critically ill patients]. / Volumen sanguíneo intratorácico versus presión arterial de oclusión pulmonar como estimadores de precarga cardíaca en pacientes críticos.

BACKGROUND: Monitoring of cardiac preload by determination of pulmonary artery occlusion pressure (PAOP) has been traditionally used to guide fluid therapy to optimize cardiac output (CO). Since factors such as intrathoracic pressure and ventricular compliance may modify PAOP, volumetric estimators of preload have been developed. The PiCCO system is able to measure CO and intrathoracic blood volume (ITBV) by transpulmonary thermodilution. AIM: To compare a volumetric (ITBV) versus a pressure (PAOP) determination to accurately estimate cardiac preload in severely ill patients. PATIENTS AND METHODS: From June 2001 to October 2003, 22 mechanically ventilated patients with hemodynamic instability underwent hemodynamic monitoring with pulmonary artery catheter (PAC) and PiCCO system. ITBV index (ITBVI), PAOP and CI were measured simultaneously by both methods. One hundred thirty eight deltas (D) were obtained from the difference of ITBVI, PAOP, CI-PAC and CI-PiCCO between 6-12 am and 6-12 pm. Linear regression analysis of DITBVI versus Eth CI-PiCCO and Eth PAOP versus DCI-PAC were made. RESULTS: Mean age of patients was 60.8 +/- 19.4 years. APACHE II was 23.9 +/- 7. Fifteen patients met criteria for acute respiratory distress syndrome (ARDS). Delta ITBVI significantly correlated with DCI-PiCCO (r=0.54; 95% confidence interval = 0.41-0.65; p <0.01). There was no correlation between DPAOP and DCI-PAC. CONCLUSION: ITBVI correlated better with CI than PAOP, and therefore it seems to be a more accurate estimator of preload in unstable, mechanically ventilated patients.