The medical treatment of cardiogenic shock.

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

Preventing and managing perioperative pulmonary complications following cardiac surgery.

PURPOSE OF REVIEW: To provide an update of research findings on the mechanisms underlying respiratory complications after cardiac surgery, especially acute respiratory distress syndrome, transfusion-related lung injury and ventilation-associated pneumonia. The article will review some of the preventive and therapeutic measures that can be implemented to reduce these complications, focusing on the use of protective invasive ventilation and postextubation noninvasive ventilation. RECENT FINDINGS: The development of postoperative pulmonary complications is related to various perioperative factors. The most effective preventive measures are a correct preoperative preparation and an uneventful surgery. The implementation of nosocomial pneumonia prevention bundles, or early extubation in a fast-track program, has proven to be effective in reducing the complication rate. The application of protective invasive ventilation, with low tidal volumes, has been found to reduce lung injury and mortality in patients with lung injury or healthy lungs. The use of noninvasive ventilation as a preventive postextubation approach in patients at risk and rescue noninvasive ventilation in those developing respiratory failure remains under debate and is subject to ongoing research. SUMMARY: Postoperative pulmonary complications are common, but severe complications are infrequent. Their reduction requires measures to prevent infection and mechanical ventilation-associated lung injury through the use of low tidal volumes and early extubation. Noninvasive ventilation after extubation can be utilized to avoid reintubation and the associated increased morbidity and mortality. However, noninvasive ventilation should be done under rigorous conditions and by following strict criteria.

[Endocarditis caused by Trichoderma longibrachiatumin a patient receiving home parenteral nutrition]. / Endocarditis por Trichoderma longibrachiatum en paciente con nutrición parenteral domiciliaria.

Home parenteral nutrition (HPN) improves the quality of life of the patients although it has complications. Catheter-related infections and mechanical complications are the most frequent ones. We report the case of endocarditis over catheter in a man suffering from short bowel and receiving HPN. The special features of the case are firstly the catheter was a remaining fragment on the right atrial and secondly the infection was caused by Trichoderma longibrachiatum, an isolated fact regarding this pathology so far. Conventional surgery was applied to take the catheter out. Staphylococcus epidermidis, Ochrobactrum anthropi and Trichoderma longibrachiatum were isolated from the surgical specimen. The extraction of the infected catheter along with antibiotic therapy led to the complete recovery of the subject. Ochrobactrum anthropi and Trichoderma longibrachiatum are unusual microorganisms but they are acquiring more relevance. Although there is no agreement about intravascular retained catheter management, the most recommended approach consists on monitoring them and removing the device in case of complications.

La modalidad domiciliaria de la nutrición parenteral (NPD) mejora la calidad de vida de los pacientes, pero tiene complicaciones como infecciones asociadas a catéter (IAC) y complicaciones mecánicas. Presentamos el caso de un paciente con NPD por intestino corto que desarrolla una endocarditis sobre catéter con matices especiales: asentar sobre un catéter abandonado en aurícula derecha y tratarse de una infección con participación de un microorganismo no descrito hasta el momento en esta patología, Trichoderma longibrachiatum. El catéter se extrajo mediante cirugía convencional. En la pieza quirúrgica se aislaron Staphylococcus epidermidis, Ochrobactrum anthropi y Trichoderma longibrachiatum. Combinando el tratamiento antibiótico y la eliminación del foco infeccioso se consiguió la recuperación completa. Ochrobactrum anthropi y Trichoderma longibrachiatum son microorganismos poco habituales, pero que cada vez adquieren mayor relevancia. Aunque no existe acuerdo en el manejo de los catéteres intravasculares "abandonados", es recomendable el seguimiento y eliminarlos en caso de complicación.

Endocarditis por Trichoderma longibrachiatum en paciente con nutrición parenteral domiciliaria / Endocarditis caused by Trichoderma longibrachiatum and parenteral nutrition

La modalidad domiciliaria de la nutrición parenteral (NPD) mejora la calidad de vida de los pacientes, pero tiene complicaciones como infecciones asociadas a catéter (IAC) y complicaciones mecánicas. Presentamos el caso de un paciente con NPD por intestino corto que desarrolla una endocarditis sobre catéter con matices especiales: asentar sobre un catéter abandonado en aurícula derecha y tratarse de una infección con participación de un microorganismo no descrito hasta el momento en esta patología, Trichoderma longibrachiatum. El catéter se extrajo mediante cirugía convencional. En la pieza quirúrgica se aislaron Staphylococcus epidermidis, Ochrobactrum anthropi y Trichoderma longibrachiatum. Combinando el tratamiento antibiótico y la eliminación del foco infeccioso se consiguió la recuperación completa. Ochrobactrum anthropi y Trichoderma longibrachiatum son microorganismos poco habituales, pero que cada vez adquieren mayor relevancia. Aunque no existe acuerdo en el manejo de los catéteres intravasculares “abandonados”, es recomendable el seguimiento y eliminarlos en caso de complicación (AU)

Home parenteral nutrition (HPN) improves the quality of life of the patients although it has complications. Catheter-related infections and mechanical complications are the most frequent ones. We report the case of endocarditis over catheter in a man suffering from short bowel and receiving HPN. The special features of the case are firstly the catheter was a remaining fragment on the right atrial and secondly the infection was caused by Trichoderma longibrachiatum, an isolated fact regarding this pathology so far. Conventional surgery was applied to take the catheter out. Staphylococcus epidermidis, Ochrobactrum anthropi and Trichoderma longibrachiatum were isolated from the surgical specimen. The extraction of the infected catheter along with antibiotic therapy led to the complete recovery of the subject. Ochrobactrum anthropi and Trichoderma longibrachiatum are unusual microorganisms but they are acquiring more relevance. Although there is no agreement about intravascular retained catheter management, the most recommended approach consists on monitoring them and removing the device in case of complications (AU)

Alveolar overdistension as a cause of lung injury: differences among three animal species.

This study analyses characteristics of lung injuries produced by alveolar overdistension in three animal species. Mechanical ventilation at normal tidal volume (10 mL/Kg) and high tidal volume (50 mL/Kg) was applied for 30 min in each species. Data were gathered on wet/dry weight ratio, histological score, and area of alveolar collapse. Five out of six rabbits with high tidal volume developed tension pneumothorax, and the rabbit results were therefore not included in the histological analysis. Lungs from the pigs and rats showed minimal histological lesions. Pigs ventilated with high tidal volume had significantly greater oedema, higher neutrophil infiltration, and higher percentage area of alveolar collapse than rats ventilated with high tidal volume. We conclude that rabbits are not an appropriate species for in vivo studies of alveolar overdistension due to their fragility. Although some histological lesions are observed in pigs and rats, the lesions do not appear to be relevant.

Postoperative respiratory failure after cardiac surgery: use of noninvasive ventilation.

OBJECTIVES: To analyze the use of noninvasive ventilation (NIV) in respiratory failure after extubation in patients after cardiac surgery, the factors associated with respiratory failure, and the need for reintubation. DESIGN: Retrospective observational study. SETTING: Intensive care unit in a university hospital. PARTICIPANTS: Patients (n = 63) with respiratory failure after extubation after cardiac surgery over a 3-year period. INTERVENTIONS: Mechanical NIV. MEASUREMENTS AND MAIN RESULTS: Demographic and surgical data, respiratory history, causes of postoperative respiratory failure, durations of mechanical ventilation and spontaneous breathing, gas exchange values, and the mortality rate were recorded. Of 1,225 postsurgical patients, 63 (5.1%) underwent NIV for respiratory failure after extubation. The median time from extubation to the NIV application was 40 hours (18-96 hours). The most frequent cause of respiratory failure was lobar atelectasis (25.4%). The NIV failed in 52.4% of patients (33/63) who had a lower pH at 24 hours of treatment (7.35 v 7.42, p = 0.001) and a higher hospital mortality (51.5% v 6.7%, p = 0.001) than those in whom NIV was successful. An interval <24 hours from extubation to NIV was a predictive factor for NIV failure (odds ratio, 4.6; 95% confidence interval, 1.2-17.9), whereas obesity was associated with NIV success (odds ratio, 0.22; 95% confidence interval, 0.05-0.91). CONCLUSIONS: Reintubation was required in half of the NIV-treated patients and was associated with an increased hospital mortality rate. Early respiratory failure after extubation (≤24 hours) is a predictive factor for NIV failure.

Alveolar fluid clearance in healthy pigs and influence of positive end-expiratory pressure.

INTRODUCTION: The objectives were to characterize alveolar fluid clearance (AFC) in pigs with normal lungs and to analyze the effect of immediate application of positive end-expiratory pressure (PEEP). METHODS: Animals (n = 25) were mechanically ventilated and divided into four groups: small edema (SE) group, producing pulmonary edema (PE) by intratracheal instillation of 4 ml/kg of saline solution; small edema with PEEP (SE + PEEP) group, same as previous but applying PEEP of 10 cmH2O; large edema (LE) group, producing PE by instillation of 10 ml/kg of saline solution; and large edema with PEEP (LE + PEEP) group, same as LE group but applying PEEP of 10 cmH2O. AFC was estimated from differences in extravascular lung water values obtained by transpulmonary thermodilution method. RESULTS: At one hour, AFC was 19.4% in SE group and 18.0% in LE group. In the SE + PEEP group, the AFC rate was higher at one hour than at subsequent time points and higher than in the SE group (45.4% vs. 19.4% at one hour, P < 0.05). The AFC rate was also significantly higher in the LE + PEEP than in the LE group at three hours and four hours. CONCLUSIONS: In this pig model, the AFC rate is around 20% at one hour and around 50% at four hours, regardless of the amount of edema, and is increased by the application of PEEP.

Intratracheal dopamine attenuates pulmonary edema and improves survival after ventilator-induced lung injury in rats.

INTRODUCTION: Clearance of alveolar oedema depends on active transport of sodium across the alveolar-epithelial barrier. beta-Adrenergic agonists increase clearance of pulmonary oedema, but it has not been established whether beta-agonist stimulation achieves sufficient oedema clearance to improve survival in animals. The objective of this study was to determine whether the increased pulmonary oedema clearance produced by intratracheal dopamine improves the survival of rats after mechanical ventilation with high tidal volume (HVT). METHODS: This was a randomized, controlled, experimental study. One hundred and thirty-two Wistar-Kyoto rats, weighing 250 to 300 g, were anaesthetized and cannulated via endotracheal tube. Pulmonary oedema was induced by endotracheal instillation of saline solution and mechanical ventilation with HVT. Two types of experiment were carried out. The first was an analysis of pulmonary oedema conducted in six groups of 10 rats ventilated with low (8 ml/kg) or high (25 ml/kg) tidal volume for 30 or 60 minutes with or without intratracheally instilled dopamine. At the end of the experiment the animals were exsanguinated and pulmonary oedema analysis performed. The second experiment was a survival analysis, which was conducted in two groups of 36 animals ventilated with HVT for 60 minutes with or without intratracheal dopamine; survival of the animals was monitored for up to 7 days after extubation. RESULTS: In animals ventilated at HVT with or without intratracheal dopamine, oxygen saturation deteriorated over time and was significantly higher at 30 minutes than at 60 minutes. After 60 minutes, a lower wet weight/dry weight ratio was observed in rats ventilated with HVT and instilled with dopamine than in rats ventilated with HVT without dopamine (3.9 +/- 0.27 versus 4.9 +/- 0.29; P = 0.014). Survival was significantly (P = 0.013) higher in animals receiving intratracheal dopamine and ventilated with HVT, especially at 15 minutes after extubation, when 11 of the 36 animals in the HVT group had died as compared with only one out of the 36 animals in the HVT plus dopamine group. CONCLUSION: Intratracheal dopamine instillation increased pulmonary oedema clearance in rats ventilated with HVT, and this greater clearance was associated with improved survival.

Early markers of acute respiratory distress syndrome development in severe trauma patients.

PURPOSE: The aim of the study was to identify early risk factors for development of acute respiratory distress syndrome (ARDS) in severe trauma patients. MATERIALS AND METHODS: This was a prospective observational study of 693 severe trauma patients (Injury Severity Score >or=16 and/or Revised Trauma Score or=2) of long bone fractures, and with chest injuries (rib/sternal fracture [ICD-9 code 807] and hemo/pneumothorax [ICD-9 code 860/861]). Patients with ARDS required more colloids (P = .005) and red blood cell units (P = .02) than patients without ARDS during the first 24 hours. Multivariate analysis showed that ARDS was related to chest trauma diagnosis (ICD-9 code 807) (odds ratio [OR], 3.85), femoral fracture (OR, 3.16), APACHE II score (OR, 1.05), and blood transfusion during resuscitation (OR, 1.32). CONCLUSIONS: Risk of ARDS development is related to the first 24-hour admission variables, including severe physiologic derangements and specific ICD-9-classified injuries. Blood transfusion may play an independent role.

Intermittent alveolar overdistension for 30 or 240 minutes does not produce acute lung injury in normal pig lung.

BACKGROUND: The objective is to study whether alveolar overdistension can induce acute lung injury in pigs as assessed by analysis of respiratory and histological parameters and inflammatory markers. MATERIALS AND METHODS: Experimental study, using mixed-breed pigs. Animals were assigned to one of the following groups: Control Group (CG) (n = 5), applying mechanical ventilation with tidal volume (Vt) of 10 ml/kg, respiratory rate (RR) of 18 bpm, and FiO2 of 1 for 240 min; High Vt for 30 min (HVt-30) Group (n = 5), applying ventilation with Vt of 50 ml/kg and RR of 8 bpm and FiO2 of 1 for 30 min, followed by ventilation as in the CG for a further 210 min; and HVt-240 Group (n = 5), applying ventilation with Vt of 50 ml/kg, RR of 8 bpm, and FiO2 of 1 for 240 min. Hemodynamic parameters, airway pressures, arterial blood gases, extravascular lung water (EVLW), and cytokines (IL-2, IL-4, IL-6, IL-10, TNF-alpha, and ITF-gamma) in plasma and bronchoalveolar lavage (BAL) were determined. Lungs were fixed with 10% formalin for histological analysis. Results are expressed as mean +/- standard deviation. The ANOVA test was used to compare measurements among the three groups. RESULTS: At 30 min, airway pressures and oxygenation of HVt-30 and HVt-240 groups were higher than those of controls [Pplateau: 39.2 +/- 5.6 and 33.0+/- 5.1 versus 12.2 +/- 1.3 (P < 0.01); PaO2/FiO2: 443.8 +/- 55 and 430.6 +/- 34 versus 194.4 +/- 77 (P < 0.01)]. In HVt-240 group, these parameters were also higher than in the other two groups at the subsequent measurement times. There were no differences among the groups in EVLW values. Cytokines were undetected or negligible in plasma and BAL in all of the groups. The histological analysis showed no changes suggestive of acute lung injury. CONCLUSIONS: In this animal model, ventilation for 4 h with large tidal volume did not cause ventilator-induced lung injury.

Small increases in extravascular lung water are accurately detected by transpulmonary thermodilution.

BACKGROUND: Detection of small (10-20%) increases in lung water may be relevant to detect incipient pulmonary edema but no clinically usable method has demonstrated this capability to date. METHODS: In six pigs weighing 28 to 35 kg, we performed 18 determinations of extravascular lung water (EVLW; transpulmonary thermodilution method) before and immediately after the intratracheal introduction of 50 mL of saline solution. Six determinations were performed in normal lung and 12 in edematous lung. RESULTS: In normal lung, the mean of EVLW increased from 245 +/- 18 mL to 288 +/- 19 mL (p < 0.001) after the intratracheal introduction of 50 mL of saline solution; therefore, 43 of the 50 mL (84%) were detected (range, 37-48 mL). In edematous lung, the EVLW increased from 491 +/- 106 mL to 530 +/- 108 mL after the introduction of 50 mL of saline solution; therefore, 39 of the 50 mL (77%) were detected (range, 15-67 mL). CONCLUSION: The transpulmonary thermodilution technique accurately detects small increases in extravascular lung water and may permit accurate diagnosis of incipient pulmonary edema.

Análisis de mortalidad en una unidad de cuidados intensivos neurotraumatológica según el sistema APACHE III / Analysis of mortality according to the APACHE III system in a neurotrauma intensive care unit

Fundamento. Analizar la mortalidad de los pacientes en una UCI neurotraumatológica de un hospital de referencia, en función de la mortalidad esperada según el sistema predictivo APACHE III en su versión española. Métodos. Estudio prospectivo realizado, durante un período de 4 meses, sobre 155 pacientes que ingresaron de forma consecutiva en una UCI neurotraumatológica de un hospital de tercer nivel. Hemos recogido las siguientes variables: edad, sexo, procedencia, diagnóstico de ingreso, comorbilidad, puntuación en el sistema APACHE III y mortalidad hospitalaria. Hemos calculado la probabilidad de muerte esperada según la fórmula española del sistema pronóstico APACHE III, y la hemos comparado con la mortalidad hospitalaria observada, aplicando el test de Hosmer-Lemeshow. Resultados. Los 155 pacientes estudiados tenían una edad de 46 (DE 19) años; el 74,2 por ciento eran varones. Alcanzaron una puntuación APACHE III de 53,5 (33,4) puntos. En cuanto a los diagnósticos, el 48,4 por ciento fueron traumatismos y el 41,9 por ciento eran pacientes neurológicos. Casi la mayoría de los enfermos ingresaron en la UCI procedentes del servicio de urgencias (43,9 por ciento); fueron trasladados desde otro hospital el 29,7 por ciento; procedían de otra planta hospitalaria el 17,4 por ciento, y el resto de pacientes procedían de cirugía. La mortalidad hospitalaria observada fue del 30,9 por ciento, y la predicha por el sistema APACHE III fue del 28,3 por ciento. El test de Hosmer-Lemeshow no demuestra diferencias estadísticamente significativas entre ambas (H = 2,94; NS).Conclusión. La mortalidad en nuestra unidad es similar a la esperada, constatándose la utilidad del sistema predictivo APACHE III, versión española, en los pacientes críticos neurotraumatológicos (AU)