Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida / Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome

Presentamos un caso de una paciente de 38 años, que acudió a urgencias por cuadro de insuficiencia respiratoria aguda severa y fue ingresada en la Unidad de Cuidados Críticos con la sospecha diagnóstica inicial de neumonía adquirida en la comunidad producida por gérmenes atípicos, que se complicó con un síndrome de distrés respiratorio agudo. Este pudo ser tratado con ventilación mecánica no invasiva. A las 48h de su ingreso se informó del crecimiento de bacilos gramnegativos en los hemocultivos, identificados posteriormente como Salmonella enteritidis. Esta información, unida a la linfopenia que presentaba la paciente, sugería un estado de inmunodepresión, por lo que se realizaron pruebas serológicas que resultaron positivas para VIH. Fueron instaurados tratamientos antimicrobianos basados en los hallazgos microbiológicos y la evolución clínica de la paciente fue favorable(AU)

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient(AU)

[Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome]. / Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida.

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.

Control de la hemorragia en el ámbito militar / Control of bleeding in the military environment

Uno de los pilares de la medicina militar es el control del shock hemorrágico. La hemorragia es la primera causa de muerte prevenible en combate, el control adecuado del sangrado se considera primordial para estimar la supervivencia del combatiente y, el apoyo terapéutico encaminado a minimizar la pérdida sanguínea supone un reto dentro la logística sanitaria militar. El objetivo del trabajo es revisar los avances médicos y logísticos en el tratamiento de la hemorragia en el ambiente militar a lo largo de los últimos conflictos, describir cuál está siendo la aportación de las Fuerzas Armadas Españolas y perfilar futuras líneas de investigación(AU)

One of the basics of military medicine is the control of haemorrhagic shock. Haemorrhage is the first cause of preventable death in combat, with the adequate control of bleeding being considered as fundamental to estimate the survival of the combatant as well as therapeutic support aimed at minimising blood loss being a challenge within military health logistics. The aim of this work is to review the medical and logistics advances in the treatment of bleeding in the military environment and combat during the latest conflicts, and to describe what is the current contribution of the Spanish Armed Forces and to profile future lines of investigation(AU)

[Control of bleeding in the military environment]. / Control de la hemorragia en el ámbito militar.

One of the basics of military medicine is the control of haemorrhagic shock. Haemorrhage is the first cause of preventable death in combat, with the adequate control of bleeding being considered as fundamental to estimate the survival of the combatant as well as therapeutic support aimed at minimising blood loss being a challenge within military health logistics. The aim of this work is to review the medical and logistics advances in the treatment of bleeding in the military environment and combat during the latest conflicts, and to describe what is the current contribution of the Spanish Armed Forces and to profile future lines of investigation.

[Resuscitation damage control in the patient with severe trauma]. / Reanimación de control de daños en el paciente adultocon trauma grave.

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.

Grupo de trabajo de insuficiencia renal aguda y técnicas continuas de depuración extrarrenal de la sección de cuidados críticos de la Sedar / No disponible

No disponible

[Urinary tract infections in a postoperative recovery unit]. / Infecciones urinarias en una unidad de reanimación.

OBJECTIVE: To analyze the frequency, etiology, risk factors, and mortality relating to urinary tract infection (UTI) in a postoperative recovery unit. MATERIALS AND METHODS: A prospective study was carried out from 1998 through 2003 of all patients who stayed longer than 48 hours in a 12-bed critical care unit and who were followed to 48 hours following discharge from the unit. A descriptive statistics were compiled and univariate and multiple variable Cox regression analyses were performed for episodes of nosocomial UTI. RESULTS: The incidence density for UTI associated with bladder catheterization was 8.4 cases per 1000 patient-days. The pathogens most frequently isolated in patients with bacteriuria were Candida albicans and Escherichia coli. The pathogen most frequently isolated in UTI in trauma patients was E. coli, whereas C. albicans was most often found in the postoperative patients. Multivariable analysis identified 3 risk factors: degree of severity on admission, duration of catheterization, and presence of diabetes mellitus. The mortality risk in patients with bladder catheterization and UTI was 2.20. CONCLUSIONS: UTIs can have serious consequences and are responsible for excess mortality. The real importance of UTI is unknown and is probably underestimated despite the publication of many studies. We found that the UTI microbiology findings were markedly different for the trauma and postoperative cohorts in our department.

Infecciones urinarias en una unidad de reanimación / Urinary tract infections in a postoperative recovery unit

OBJETIVOS: Conocer la frecuencia, etiología, factores deriesgo, y mortalidad relacionados con la infección del tractourinario (ITU) en una Unidad de Reanimación.MATERIAL Y MÉTODOS: Estudio prospectivo de los años1998-2003, ambos inclusive, de todos los pacientes coningreso superior a 48 horas y con seguimiento hasta las 48horas posteriores al alta de una unidad de cuidados críticospolivalentes de 12 camas. Análisis descriptivo, univariantey multivariable con regresión de Cox para los episodiosde ITU nosocomiales.RESULTADOS: La densidad de incidencia de ITU asociadaa sondaje vesical es de 8,4 por 1.000 pacientes-día. Lospatógenos aislados con más frecuencia en los pacientes conbacteriuria son Candida albicans y Escherichia coli. El germenaislado con más frecuencia en las ITU de los pacientestraumáticos es Escherichia coli, mientras que Candidaalbicans predomina en la cohorte de pacientes postquirúrgicos.Tras el análisis multivariable, tres son los factores deriesgo hallados: grado de severidad a la admisión, duraciónde la cateterización y la presencia de diabetes mellitas.El riesgo de mortalidad en pacientes con sondaje urinarioe ITU es de 2,20.CONCLUSIONES: Las ITU tienen consecuencias potencialmentegraves y son responsables de sobremortalidad. Sedesconoce su importancia real y probablemente se lasubestima pese a la publicación de múltiples estudios. Secomprueba que la microbiología de la ITU de las cohortestraumáticas y postquirúrgicas es marcadamente diferenteen nuestra unidad (AU)

OBJETIVE: To analyze the frequency, etiology, riskfactors, and mortality relating to urinary tract infection(UTI) in a postoperative recovery unit.MATERIALS AND METHODS: A prospective study wascarried out from 1998 through 2003 of all patients whostayed longer than 48 hours in a 12-bed critical care unitand who were followed to 48 hours following dischargefrom the unit. A descriptive statistics were compiled andunivariate and multiple variable Cox regression analyseswere performed for episodes of nosocomial UTI.RESULTS: The incidence density for UTI associated withbladder catheterization was 8.4 cases per 1000 patientdays.The pathogens most frequently isolated in patientswith bacteriuria were Candida albicans and Escherichiacoli. The pathogen most frequently isolated in UTI intrauma patients was E coli, whereas C albicans was mostoften found in the postoperative patients. Multivariableanalysis identified 3 risk factors: degree of severity onadmission, duration of catheterization, and presence ofdiabetes mellitus. The mortality risk in patients withbladder catheterization and UTI was 2.20.CONCLUSIONS: UTIs can have serious consequences andare responsible for excess mortality. The real importanceof UTI is unknown and is probably underestimateddespite the publication of many studies. We found that theUTI microbiology findings were markedly different for thetrauma and postoperative cohorts in our department (AU)

Hematoma epidural cervcotorácico espontáneo / No disponible

No disponible

[Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit]. / Incidencia de las neumonías nosocomiales precoces y tardías asociadas a ventilación mecánica en una unidad de reanimación- críticos polivalente.

OBJECTIVES: To ascertain the frequency, risk factors, and causes of early- and late-onset ventilator-associated pneumonia (VAP) in a postanesthesia and critical care unit. MATERIAL AND METHODS: A prospective study was carried out between January 1, 1996 and December 31, 2001 of all ventilated patients staying longer than 48 hours in the critical care unit, with follow-up for 48 hours following discharge from the unit. Descriptive statistics were compiled for episodes of early- and late-onset VAP for a period of up to 4 days after intubation; univariate and multiple variable Cox regression analyses were also carried out. RESULTS: A total of 3614 patients were admitted to the unit (study cohort, 652 patients). The mean length of stay in the unit for the study cohort was 13.64 days. The most frequent diagnosis was multiple trauma (50.46%). The incidence density of VAP was 20.31 cases per 1000 patient-days on mechanical ventilation. The pathogens most often isolated in early-onset VAP cases were Staphylococcus aureus and Pseudomonas aeruginosa. In late-onset cases, the pathogens were Pseudomonas species. Early-onset VAP was 2.54 and 2.81 times more frequent in comatose and head-injury patients, respectively. Those rates were significantly different in late-onset cases. CONCLUSIONS: Early-onset VAP was more common in comatose and head-injury patients. The risk of developing late-onset versus early-onset VAP was twice as great for postoperative patients.

Incidencia de las neumonías nosocomiales precoces y tardías asociadas a ventilación mecánica en una unidad de reanimacióncríticos polivalente / Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit

OBJETIVO: Conocer la frecuencia, factores de riesgo y etiología de neumonía nosocomial (NN) asociada a ventilación mecánica (NAVM) precoz y tardía en Unidad de Críticos polivalente (UR). MATERIAL Y MÉTODOS: Estudio prospectivo desde 1/01/1996 al 31/12/2001 de todos los pacientes ventilados con ingreso superior a 48 horas, con seguimiento hasta las 48 horas posteriores al alta de la Unidad. Análisis descriptivo, univariante y multivariable con regresión de Cox para los episodios de NAVM precoz y tardía, con un periodo de corte de 4 días postintubación. RESULTADOS: El total de pacientes ingresados fue de 3.614 pacientes (cohorte de estudio: 652 pacientes). La media de la estancia en la UR para la cohorte fue de 13,64 días. El diagnostico más frecuente (50,46%) fue el paciente politraumatizado. La densidad de incidencia de NAVM fue de 20,31 NN por 1.000 pacientes-día de ventilación mecánica. En la neumonía precoz los patógenos más frecuentemente aislados fueron Staphylococcus aureus y Pseudomonas aeruginosa, en los casos de neumonías tardías resalta el género Pseudomonas. La NAVM precoz fue 2,54 y 2,81 veces más frecuente en pacientes en estados comatosos y en enfermos con traumatismo craneoencefálico de forma respectiva, con diferencias estadísticamente significativas con respecto a los pacientes con NAVM tardía. CONCLUSIONES: La NAVM precoz fue más frecuente en pacientes con estados comatosos y con traumatismo craneoencefálico. La presencia de intervención quirúrgica supuso el doble de riesgo de desarrollar una NAVM tardía en relación a las precoces

OBJECTIVES: To ascertain the frequency, risk factors, and causes of early- and late-onset ventilator-associated pneumonia (VAP) in a postanesthesia and critical care unit. MATERIAL AND METHODS: A prospective study was carried out between January 1, 1996 and December 31, 2001 of all ventilated patients staying longer than 48 hours in the critical care unit, with follow-up for 48 hours following discharge from the unit. Descriptive statistics were compiled for episodes of early- and lateonset VAP for a period of up to 4 days after intubation; univariate and multiple variable Cox regression analyses were also carried out. RESULTS: A total of 3614 patients were admitted to the unit (study cohort, 652 patients). The mean length of stay in the unit for the study cohort was 13.64 days. The most frequent diagnosis was multiple trauma (50.46%). The incidence density of VAP was 20.31 cases per 1000 patientdays on mechanical ventilation. The pathogens most often isolated in early-onset VAP cases were Staphylococcus aureus and Pseudomonas aeruginosa. In late-onset cases, the pathogens were Pseudomonas species. Early-onset VAP was 2.54 and 2.81 times more frequent in comatose and head-injury patients, respectively. Those rates were significantly different in late-onset cases. CONCLUSIONS: Early-onset VAP was more common in comatose and head-injury patients. The risk of developing late-onset versus early-onset VAP was twice as great for postoperative patients

[Intracranial hypotension syndrome treated with an epidural blood patch]. / Síndrome de hipotensión intracraneal espontánea tratada con parche hemático epidural.

A 41-year-old woman was admitted to the internal medicine department to assess incapacitating postural headache. Clinical findings suggested the need for computed tomography and nuclear magnetic resonance scanning of the head, which led to a diagnosis of spontaneous intracranial hypotension syndrome. Later, isotopic cysternography and nuclear magnetic resonance imaging of the spine were used unsuccessfully to try to locate the cerebrospinal fluid leak that caused the syndrome. When conservative treatment proved ineffective, the pain clinic was called in to perform an epidural blood patch procedure. The patch led to an improvement in symptoms and the syndrome resolved completely after a second lumbar blood patch was used.

Síndrome de hipotensión intracraneal espontánea tratada con parche hemático epidural / Intracranial hypotension syndrome treated with an epidural blood patch

Paciente mujer de 41 años que ingresó en el servicio de Medicina Interna para estudio de cefalea postural invalidante. Ante los hallazgos clínicos se le realizó una tomografía axial computerizada y resonancia magnética nuclear craneales llegando al diagnóstico de síndrome de hipotensión intracraneal espontáneo. Posteriormente se intentó localizar el punto de fuga de líquido cefalorraquídeo causante del síndrome mediante cisternografía isotópica y resonancia magnética nuclear de columna sin éxito. El tratamiento conservador resultó ineficaz y se solicitó la colaboración de la unidad de dolor para la realización de un parche hemático epidural. La aplicación de un parche epidural a nivel dorsal mejoró los síntomas, que se resolvieron definitivamente tras un segundo parche a nivel lumbar

A 41-year-old woman was admitted to the internal medicine department to assess incapacitating postural headache. Clinical findings suggested the need for computed tomography and nuclear magnetic resonance scanning of the head, which led to a diagnosis of spontaneous intracranial hypotension syndrome. Later, isotopic cysternography and nuclear magnetic resonance imaging of the spine were used unsuccessfully to try to locate the cerebrospinal fluid leak that caused the syndrome. When conservative treatment proved ineffective, the pain clinic was called in to perform an epidural blood patch procedure. The patch led to an improvement symptoms and the syndrome resolved completely after a second lumbar blood patch was used

[Four patients with mucormycosis in a postoperative recovery unit]. / Estudio descriptivo de cuatro pacientes afectados de mucormicosis ingresados en nuestra unidad de reanimación.

Mucormycosis, a rare opportunistic infection caused by fungi belonging to the Mucorales order, is a potentially fatal disease. We describe 4 patients with mucormycosis. Risk factors (chronic renal insufficiency and chronic lung disease treated with corticosteroids) were identified for 2 of the patients who did not respond favorably to appropriate surgical and medical treatment. Of the 2 remaining patients, only the one with milder disease responded to treatment. The prognosis for this opportunistic infection, whose low incidence has increased in postoperative intensive care units, is very poor if early treatment is not given.