Asunto(s)
Infecciones por Actinomycetales/complicaciones , Nocardiosis/complicaciones , Sarcoidosis Pulmonar/complicaciones , Glucocorticoides/efectos adversos , Seronegatividad para VIH , Humanos , Huésped Inmunocomprometido , Masculino , Persona de Mediana Edad , Nocardia , Infecciones Oportunistas/microbiología , Prednisona/efectos adversos , Rhodococcus equi , Sarcoidosis Pulmonar/tratamiento farmacológicoAsunto(s)
Antivirales/uso terapéutico , Colitis Ulcerosa/virología , Infecciones por Citomegalovirus/inmunología , Ganciclovir/uso terapéutico , Enfermedad Aguda , Adulto , Transfusión Sanguínea , Colitis Ulcerosa/tratamiento farmacológico , Colitis Ulcerosa/inmunología , Infecciones por Citomegalovirus/tratamiento farmacológico , Humanos , Inmunocompetencia , MasculinoRESUMEN
We report a case of a 17-year-old patient with an haemothorax related to an intra-abdominal spleen rupture. The nature of this haemothorax is unusual and the problem is how to obtain the etiology in this case. The spleen was in intra-abdominal position on all radiological examinations and was the source of bleeding. Therefore, laparotomy is the only convenient therapy.
Asunto(s)
Hemotórax/etiología , Rotura del Bazo/complicaciones , Accidentes de Tránsito , Adolescente , Hemotórax/diagnóstico por imagen , Hemotórax/cirugía , Humanos , Laparotomía , Masculino , Radiografía , Bazo/diagnóstico por imagen , Rotura del Bazo/diagnóstico por imagen , Rotura del Bazo/cirugíaRESUMEN
STUDY OBJECTIVES: Contrast transthoracic echocardiography (TTE) is currently used to identify intrapulmonary shunt (IPS) in patients with end-stage liver disease. The aim of this study was to compare the use of contrast TTE and transesophageal echocardiography (TEE) in detecting IPS. DESIGN: Thirty-seven consecutive outpatients with severe liver disease awaiting liver transplantation underwent contrast TEE and TTE. The IPS was assessed semiquantitatively in four grades with TEE and as positive or negative with TTE. SETTING: ICU. INTERVENTIONS: Patients underwent contrast TEE after pharyngeal anesthesia alone followed by contrast TTE. Contrast echocardiography was performed with a modified fluid gelatin solution. RESULTS: Overall detection rate of an IPS was 51% with TEE and 32% with TTE (p < 0.001). Four patients had an IPS detected with TEE but not with TTE. Quality of imaging was poor in 22% with TTE and 0% with TEE (p < 0.001). A PaO2 < 80 mm Hg or a dyspnea was associated with an IPS in 56% and 50% of patients with TEE and in 33% and 25% with TTE, respectively. CONCLUSION: Contrast-enhanced TEE is superior to TTE for detecting an IPS in patients with severe liver disease awaiting liver transplantation. The use of gelatin contrast solution allows an early detection of IPS. Because of the high sensitivity of TEE, all patients suspected of hepatopulmonary syndrome should undergo TEE in search of an IPS if TTE is normal.
Asunto(s)
Fístula Arteriovenosa/diagnóstico por imagen , Medios de Contraste , Ecocardiografía Transesofágica , Ecocardiografía , Fallo Hepático/complicaciones , Pulmón/irrigación sanguínea , Disnea/complicaciones , Femenino , Gelatina , Hepatitis Crónica/complicaciones , Humanos , Aumento de la Imagen , Hepatopatías Alcohólicas/complicaciones , Fallo Hepático/diagnóstico por imagen , Fallo Hepático/cirugía , Trasplante de Hígado , Enfermedades Pulmonares/complicaciones , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Circulación Pulmonar , Sensibilidad y Especificidad , SíndromeRESUMEN
Percutaneous tracheostomy, a technique that can be performed at the bedside in the intensive care unit (ICU), is increasingly used for critically ill ventilator-dependent patients. Based on many clinical studies, this procedure appears to be simple, rapid and safer than conventional surgical tracheostomy. This technique produces a stoma tissue tract that fits snugly around the cannula, and this could explain the low incidence of infective complications. However, we report two cases of life-threatening cellulitis, a serious complication that has rarely been reported previously.
Asunto(s)
Celulitis (Flemón)/etiología , Cuidados Críticos/métodos , Traqueostomía/efectos adversos , Infección de Heridas/etiología , Adulto , Anciano , Celulitis (Flemón)/microbiología , Humanos , Masculino , Traqueostomía/métodosRESUMEN
PURPOSE: To assess the effects of controlled ventilation with two I:E ratios on haemodynamic and left ventricular function in mechanically ventilated patients with moderate to severe respiratory disease, using fluctuation of the arterial pressure waveform and the changes in left ventricular areas obtained by transoesophageal echocardiography. METHODS: Nine patients had their lungs ventilated using volume controlled ventilation with two I:E ratios 1:3 and 1:1). Respiratory rate was adjusted so that six cardiac beats occurred during a respiratory cycle. Systolic blood pressure variation (SBPV), left ventricular area variations measured by TEE and haemodynamic variables measured by PA catheter were compared. RESULTS: When compared with I:E (1:3), I:E (1:1) decreased end diastolic area (EDA) throughout the respiratory cycle from 3% to 8% (P < 0.01) and increased SBPV from 6 +/- 1 to 11 +/- 1 mmHg (P < 0.01). In four patients, SBPV was > 12 mmHg with I:E 1:1. Conversely, SBPV was < 10 mmHg in all patients with I:E 1:3. With I:E (1:1), EDA decreased up to 7% during expiration (P < 0.01). The ejection fraction area remained stable for both ventilatory patterns and throughout the ventilatory cycle for a given I:E. The usual invasive haemodynamic variables were unchanged throughout the study, as was PaO2/FIO2. CONCLUSION: In this setting, EDA and SBPV allow beat-to-beat evaluation of left ventricular preload during change of I:E ratio. Switch from I:E 1:3 to 1:1 may be used as a rapid, safe and reversible test to estimate intravascular volume status assessed by changes in SBPV or EDA.
Asunto(s)
Ecocardiografía Transesofágica , Respiración con Presión Positiva/métodos , Adulto , Anciano , Presión Sanguínea , Dióxido de Carbono/sangre , Volumen Cardíaco , Cateterismo de Swan-Ganz , Diástole , Electrocardiografía , Femenino , Frecuencia Cardíaca , Ventrículos Cardíacos/diagnóstico por imagen , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Estudios Prospectivos , Respiración , Insuficiencia Respiratoria/terapia , Volumen Sistólico , Sístole , Función Ventricular IzquierdaRESUMEN
Necrotizing fasciitis is a rapidly progressing necrotizing process which affects subcutaneous tissue and fascia. The leading cause of these infections in neck is odontogenic infection. Its occurrence is reported to be rare, but often fatal. The therapeutic regimen includes three essential principles: appropriate antimicrobial therapy, prompt surgical treatment, and supportive measures. Two cases of cervical necrotizing fasciitis revealing human immunodeficiency virus (HIV) infection are reported. Clinicians should be aware of this underlying condition, and every patient with cervical necrotizing fasciitis should be tested for HIV.
Asunto(s)
Celulitis (Flemón)/etiología , Fascitis Necrotizante/etiología , Infecciones por VIH/complicaciones , Absceso Periapical/complicaciones , Adulto , Celulitis (Flemón)/terapia , Desbridamiento , Drenaje , Fascitis Necrotizante/terapia , Femenino , Humanos , Masculino , CuelloRESUMEN
OBJECTIVE: To assess the efficacy of intramuscular ephedrine for prevention of hypotension following subarachnoid block (SB) in the elderly. STUDY DESIGN: Prospective, randomized double blind study vs placebo. PATIENTS: Twenty patients, aged 60 years or more, of physical class ASA 2 or 3, scheduled for surgical fixation of fractured neck of femur under SB, allocated into two groups of ten each. METHODS: After oral premedication with hydroxyzine 50 mg, 90 min before surgery, and preloading with cristalloid solution 10 mL.kg-1, the subarachnoid space was punctured with the patient in lateral position using a 22 Gauge spinal needle at the L3-L4 or L4-L5 interspace. Patients were given 0.5% hyperbaric bupivacaine intrathecally, according to body weight. Patients in ephedrine group received intramuscular ephedrine 30 mg immediately after SB. Patients in placebo group received 1 mL of intramuscular saline immediately after SB. When blood pressure decreased below 100 mmHg repeated bolus of ephedrine 6 mg were given intravenously. RESULTS: Patients in both groups experienced a significant decrease in systolic pressure after SB, the decrease being significantly greater in the placebo group. CONCLUSION: Prophylactic intramuscular ephedrine is effective to prevent hypotension associated with SB in the elderly.
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Anestesia Raquidea , Anestésicos Locales/efectos adversos , Bupivacaína/efectos adversos , Efedrina/uso terapéutico , Hemodinámica/efectos de los fármacos , Hipotensión/prevención & control , Complicaciones Intraoperatorias/prevención & control , Bloqueo Nervioso , Vasoconstrictores/uso terapéutico , Anciano , Anciano de 80 o más Años , Anestésicos Locales/farmacología , Bupivacaína/farmacología , Método Doble Ciego , Efedrina/administración & dosificación , Efedrina/farmacología , Fracturas del Cuello Femoral/cirugía , Fijación de Fractura , Humanos , Hipotensión/inducido químicamente , Inyecciones Intramusculares , Estudios Prospectivos , Espacio Subaracnoideo , Vasoconstrictores/administración & dosificación , Vasoconstrictores/farmacologíaRESUMEN
STUDY OBJECTIVE: To assess the usefulness of quantification of infected cells (ICs) in BAL fluid for the diagnosis of ventilator-associated pneumonia (VAP). DESIGN: A prospective study. SETTING: A medico-surgical ICU in a tertiary health-care institution. PATIENTS: One hundred thirty-two patients (mean age, 52 +/- 19 years). The suspicion of nosocomial pneumonia was strong in these patients: all had fever (> or = 38.5 degrees C), purulent tracheal aspirates, leukocytosis (> or = 10,000 cells per cubic millimeter), and new or persistent radiographic lung infiltrates. INTERVENTIONS: One hundred sixty-three samples (BAL and protected specimen brushes [PSB]) were obtained. RESULTS: VAP was present in 56 cases. The diagnosis was excluded in the remaining 107 cases. The IC count was performed on 100 cells in BAL fluid. The percentage of IC was significantly higher (12.6 +/- 12.4 vs 1.14 +/- 3.39; p < 0.0001) in patients with pneumonia: the area under the receiver operating characteristic (ROC) curve was 0.888 and a threshold of 2% of IC corresponded to a sensitivity of 84%, a specificity of 80%, a positive predictive value of 69%, and a negative predictive value of 90%. CONCLUSIONS: It is possible to define a threshold of IC in BAL fluid with a good reliability by using an ROC curve. This technique is useful for the early diagnosis (< 2 h) of nosocomial bacterial pneumonia in mechanically ventilated patients and allows a rapid and appropriate treatment of most of the patients with suspected VAP.
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Líquido del Lavado Bronquioalveolar/citología , Neumonía Bacteriana/diagnóstico , Respiración Artificial/efectos adversos , Recuento de Células , Células/microbiología , Colorantes , Humanos , Persona de Mediana Edad , Neumonía Bacteriana/etiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Sensibilidad y EspecificidadRESUMEN
The authors report a case of rupture of a mycotic aneurysm of the duodenal pancreatic arcade in a 68 year old man presenting with shock, abdominal pain and rigidity, complicating a case of infectious endocarditis. Emergency treatment consisted of selective embolisation with a coil. This treatment, proposed in view of the clinical condition of the patient and the anatomical particularity of the regional arterial vascularisation, may be a valuable alternative to classical surgery in this type of pathology.
Asunto(s)
Aneurisma Infectado/etiología , Aneurisma Roto/etiología , Embolización Terapéutica/métodos , Endocarditis Bacteriana/complicaciones , Arteria Mesentérica Superior , Infecciones Estreptocócicas/complicaciones , Anciano , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/terapia , Aneurisma Roto/diagnóstico , Aneurisma Roto/terapia , Angiografía , Antibacterianos/uso terapéutico , Embolización Terapéutica/instrumentación , Endocarditis Bacteriana/diagnóstico , Estudios de Seguimiento , Humanos , Masculino , Stents , Infecciones Estreptocócicas/diagnóstico , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: Staphylococcus aureus is one of the prominent causative agents of ventilator-associated pneumonia (VAP). Gram staining of bronchoalveolar lavage (BAL) fluid is not always reliable. A nonisotopid probe (Accuprobe) has been developed by Gen-Probe for the specific identification of S. aureus isolated from cultures. This study was undertaken to assess the reliability of this probe for the early diagnosis of S. aureus VAP. DESIGN: A prospective study in 120 consecutive patients. SETTING: Department of intensive care medicine at a university hospital. PATIENTS: 120 ventilated patients (70 males and 50 females; mean age 52 +/- 12 years; mean simplified acute physiologic score = 13 +/- 4) were studied. INTERVENTIONS: 164 bronchoalveolar lavages were performed (none of the patients received prior antibiotic therapy). MEASUREMENTS AND RESULTS: S. aureus was identified 29 times at significant concentrations (> or = 10(4) cfu/ml) and 7 times at < 10(4) cfu/ml. The sensitivity and specificity of the Accuprobe system were 100 and 96%, respectively. We found agreement between quantitative cultures and probes in 96.3% of cases. CONCLUSIONS: We conclude that this probe provides a rapid (< or = 7 h) and accurate diagnosis of S. aureus pulmonary infection.
Asunto(s)
Líquido del Lavado Bronquioalveolar/microbiología , Sondas de ADN , ADN Bacteriano/análisis , Staphylococcus aureus , Anciano , Infección Hospitalaria/microbiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/microbiología , Estudios Prospectivos , Reproducibilidad de los Resultados , Respiración Artificial/efectos adversos , Sensibilidad y Especificidad , Infecciones Estafilocócicas/microbiologíaRESUMEN
The pyogenic liver abscess is an uncommon but potentially lethal complication of colo-anal surgery. The authors report a case due to Streptococcus intermedius, a pathogen with a known ability to produce visceral abscesses, after haemorrhoidectomy. According to the French consensus conference, the patient had received a prophylactic preoperative antibiotic regimen consisting of metronidazole, active against S intermedius. Despite surgical therapy and adequate antibiotics, the patient died of hepatic failure.
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Hemorroides/cirugía , Absceso Hepático/etiología , Complicaciones Posoperatorias/microbiología , Infecciones Estreptocócicas/etiología , Resultado Fatal , Humanos , Absceso Hepático/microbiología , Masculino , Persona de Mediana Edad , Infecciones Estreptocócicas/microbiologíaRESUMEN
The authors report a case of a woman who had two episodes of a tricuspid Saint-Jude prosthesis thrombosis treated with fibrinolysis using rt-PA, during the fourth month of pregnancy. A first course of thrombolytic therapy was successful with normal valve function despite threatening abortion and uterine bleeding. An early rethrombosis of the prosthetic valve and a failure of a second course of thrombolysis required the interruption of pregnancy with a replacement of the tricuspid valve prosthesis.
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Prótesis Valvulares Cardíacas/efectos adversos , Activadores Plasminogénicos/uso terapéutico , Complicaciones Cardiovasculares del Embarazo/tratamiento farmacológico , Terapia Trombolítica , Trombosis/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Aborto Terapéutico , Adulto , Femenino , Humanos , Metrorragia/etiología , Embarazo , Recurrencia , Válvula TricúspideRESUMEN
A 69-year-old man, with a history of angina pectoris treated with verapamil, was admitted in the intensive care unit after a right liver resection. On admission, the chest X ray and the arterial blood gases (PaO2/FlO2 = 320) were normal. There after, the patient exhibited brief decreases of SpO2 (at 82%) which were spontaneously reversible. The ECG showed an isorhythmic atrioventricular dissociation associated with SpO2 falls. The SpO2 returned to normal values when cardiac rhythm became sinusal again. This case shows that in case of an important and brief decrease in SpO2, unexplained by a respiratory cause, a decrease of arterial pressure due to rhythmic disease should be considered.
Asunto(s)
Arritmias Cardíacas/etiología , Enfermedad Coronaria/complicaciones , Hepatectomía/efectos adversos , Anciano , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Monitoreo de Gas Sanguíneo Transcutáneo , Frecuencia Cardíaca , Humanos , Hipotensión/complicaciones , Hipotensión/terapia , Masculino , Periodo PosoperatorioRESUMEN
The effects of lipid administration on carbohydrate oxidation rate remain controversial, particularly in critically ill patients. The aim of this study was to determine the effects of these patients of a continuous lipid infusion on glucose metabolism using indirect calorimetry and stable isotopes. We studied seven patients, mechanically ventilated, during two consecutive 24-h periods. Throughout the first period they received a continuous infusion of glucose (2 mg.kg-1.min-1) and amino acids. During the second period, in addition to the glucose, they received a continuous infusion of 1 mg.kg-1.min-1 of long-chain triglycerides emulsion. Substrate oxidation rates were calculated from pulmonary gas exchange and nitrogen excretion measurements. Glucose kinetic parameters were measured using primed constant infusions of [6,6-2H2]glucose and [1-13C]glucose. The lipid infusion did not modify the glucose metabolism parameters; 45% of the lipid supply was stored.