Prevention of acute kidney injury in Intensive Care Units / Prevención de la lesión renal aguda en las unidades de cuidados intensivos

Acute kidney injury (AKI) is a growing concern in Intensive Care Units. The advanced age of our patients, with the increase in associated morbidity and the complexity of the treatments provided favor the development of AKI. Since no effective treatment for AKI is available, all efforts are aimed at prevention and early detection of the disorder in order to establish secondary preventive measures to impede AKI progression. In critical patients, the most frequent causes are sepsis and situations that result in renal hypoperfusion; preventive measures are therefore directed at securing hydration and correct hemodynamics through fluid perfusion and the use of inotropic or vasoactive drugs, according to the underlying disease condition. Apart from these circumstances, a number of situations could lead to AKI, related to the administration of nephrotoxic drugs, intra-tubular deposits, the administration of iodinated contrast media, liver failure and major surgery (mainly heart surgery). In these cases, in addition to hydration, there are other specific preventive measures adapted to each condition

La lesión renal aguda (LRA) constituye un problema de importancia creciente en las unidades de cuidados intensivos. La mayor edad de nuestros pacientes, con el aumento de la morbilidad asociada, y la complejidad de los tratamientos realizados favorecen su desarrollo. Puesto que la LRA carece de tratamiento eficaz, todos los esfuerzos se dirigen a la prevención y a su detección precoz con el fin de establecer medidas de prevención secundaria que impidan su progresión. En el paciente crítico, las causas más frecuentemente implicadas son la sepsis y las situaciones que provocan hipoperfusión renal, por lo que las medidas preventivas irán encaminadas a mantener un estado de hidratación y hemodinámico correcto mediante perfusión de fluidos y el uso de fármacos inotrópicos o vasoactivos en función de la enfermedad subyacente. Además de estas circunstancias, existen distintas situaciones que pueden favorecer la LRA, relacionadas con la administración de fármacos nefrotóxicos, los depósitos intratubulares, la administración de contrastes iodados, el fallo hepático y la cirugía mayor, fundamentalmente cirugía cardiaca. En estos casos, además de la hidratación, se dispone de otros aspectos preventivos específicos de cada entidad

Prevention of acute kidney injury in Intensive Care Units.

Acute kidney injury (AKI) is a growing concern in Intensive Care Units. The advanced age of our patients, with the increase in associated morbidity and the complexity of the treatments provided favor the development of AKI. Since no effective treatment for AKI is available, all efforts are aimed at prevention and early detection of the disorder in order to establish secondary preventive measures to impede AKI progression. In critical patients, the most frequent causes are sepsis and situations that result in renal hypoperfusion; preventive measures are therefore directed at securing hydration and correct hemodynamics through fluid perfusion and the use of inotropic or vasoactive drugs, according to the underlying disease condition. Apart from these circumstances, a number of situations could lead to AKI, related to the administration of nephrotoxic drugs, intra-tubular deposits, the administration of iodinated contrast media, liver failure and major surgery (mainly heart surgery). In these cases, in addition to hydration, there are other specific preventive measures adapted to each condition.

Bronconeumonitis por virus herpes simple en paciente con fallo respiratorio postoperatorio / Herpes simplex virus bronchopneumonitis in patient with acute respiratory failure after surgery

La bronconeumonitis por virus herpes simple (VHS) es una entidad clínica descrita en pacientes críticos, asociada clásicamente a estados de inmunosupresión. Estudios recientes han demostrado una elevada frecuencia de detección del virus en muestras del tracto respiratorio inferior (obtenidas por lavado broncoalveolar [BAL]) de pacientes críticos inmunocompetentes ventilados mecánicamente, lo que indicaría su papel como sustrato patogénico independiente. Presentamos el caso de una paciente que ingresa tras intervención quirúrgica de neoplasia de recto, con sospecha de broncoaspiración durante la inducción anestésica. Presenta evolución clínica marcada por fiebre persistente pese a tratamiento antibiótico de amplio espectro, ausencia de crecimiento bacteriano en los cultivos obtenidos, sin claros infiltrados radiológicos y ventilación mecánica prolongada con reiterados fracasos en el destete, y que precisa traqueostomía percutánea. Se realiza broncoscopia con BAL y se detecta VHS (a nivel microbiológico e histológico), por lo que se inicia tratamiento con aciclovir con mejoría clínica y retirada del soporte ventilatorio (AU)

Herpes simplex virus bronchopneumonitis is a clinical entity described in critically ill patients and classically associated to immunosuppression. Recent reports have shown a higher frequency of virus detection from samples obtained by bronchoalveolar lavage of immunocompetent critically ill patients undergoing mechanical ventilation. This fact suggests its role as an independent pathogenic substrate. We report the case of a female patient who was admitted after an elective surgery of rectal tumor with suspected bronchoaspiration during anesthetic induction. The patient presented persistent fever despite broad spectrum antibiotic treatment. All cultures were negative for bacterial growth. The chest X-ray did not show opacifities. Prolonged mechanical ventilation with repeated failures to wean made it mandatory to perform percutaneous tracheostomy. A fibrobronchoscopy with bronchoalveolar lavage, performed previously, showed positive result for herpes simplex virus (PCR and specific nuclear inclusions in cells). Thus, treatment was initiated with acyclovir, with clinical improvement and weaning from mechanical ventilation (AU)

[Herpes simplex virus bronchopneumonitis in patient with acute respiratory failure after surgery]. / Bronconeumonitis por virus herpes simple en paciente con fallo respiratorio postoperatorio.

Herpes simplex virus bronchopneumonitis is a clinical entity described in critically ill patients and classically associated to immunosuppression. Recent reports have shown a higher frequency of virus detection from samples obtained by bronchoalveolar lavage of immunocompetent critically ill patients undergoing mechanical ventilation. This fact suggests its role as an independent pathogenic substrate. We report the case of a female patient who was admitted after an elective surgery of rectal tumor with suspected bronchoaspiration during anesthetic induction. The patient presented persistent fever despite broad spectrum antibiotic treatment. All cultures were negative for bacterial growth. The chest X-ray did not show opacifities. Prolonged mechanical ventilation with repeated failures to wean made it mandatory to perform percutaneous tracheostomy. A fibrobronchoscopy with bronchoalveolar lavage, performed previously, showed positive result for herpes simplex virus (PCR and specific nuclear inclusions in cells). Thus, treatment was initiated with acyclovir, with clinical improvement and weaning from mechanical ventilation.