RESUMEN
Se describen dos casos de lesión de Dieulafoy, la cual es definida como una anormalidad de una arteria grande o arteriola, que conserva su calibre al aproximarse a la mucosa. Esta lesión suele presentarse como sangrado gastrointestinal masivo no doloroso e inestabilidad hemodinámica y puede ser causa de hemorragia gastrointestinal fatal. El diagnóstico definitivo es anatomopatológico aunque con la endoscopia se puede alcanzar una precisión elevada siendo esta última el tratamiento de elección. La enfermedad presentaba una mortalidad cercana al 80% antes de la terapia endoscópica y gracias a esta actualmente se ha reducido al 13%. La experiencia del endoscopista y los recursos disponibles influyen en forma directa con la eficacia en el diagnostico, tratamiento y sobrevida de los pacientes.
Two cases of Dieulafoy lesion, defined as a malformation in a large artery or arteriole that retains its caliber when approaching the mucosa, are described here. This lesion usually causes non-painful massive gastrointestinal bleeding and hemodynamic instability and can cause a fatal gastrointestinal hemorrhage. The definitive diagnosis is pathologic, although a high precision can be achieved by endoscopy, that is the treatment of choice. The disease had a mortality rate near 90% before the endoscopic therapy and, thanks to it, it has currently been reduced to 13%. The endoscopist's experience and the available resources influence directly on the effectiveness of diagnosis, management and survival of patients.
Asunto(s)
Pediatría , Informes de Casos , Anomalías del Sistema Digestivo , Endoscopía , Hemorragia GastrointestinalRESUMEN
OBJECTIVE: To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN: Prospective cohort. SETTING: Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS: All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS: Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.
