[Recommendations for the use of thromboprophylaxis in hospitalized patients with COVID-19 in Argentina]. / Recomendaciones para el uso de tromboprofilaxis en pacientes hospitalizados por COVID-19 en la Argentina.

Although the incidence is uncertain, some case reports suggest that COVID 19 infection is associated with an increased risk of venous thromboembolism. We suggest starting prophylactic anticoagulant therapy for all patients hospitalized with a symptomatic infection with COVID-19, unless contraindicated, with enoxaparin 40 mg SC daily if creatinine clearance is greater than 30 ml/min.

Si bien la incidencia es incierta, algunos reportes de caso sugieren que la infección por COVID 19 se asocia con un aumento del riesgo de tromboembolismo venoso. Sugerimos iniciar tromboprofilaxis a todos los pacientes hospitalizados por síntomas asociados con una infección por COVID-19, a menos que esté contraindicado, con enoxaparina 40 mg SC diariamente si el clearance de creatinina es mayor a 30 ml/min.

Recomendaciones para el uso de tromboprofilaxis en pacientes hospitalizados por COVID-19 en la Argentina / Recommendations for the use of thromboprophylaxis in hospitalized patients with COVID-19 in Argentina

Si bien la incidencia es incierta, algunos reportes de caso sugieren que la infección por COVID 19 se asocia con un aumento del riesgo de tromboembolismo venoso. Sugerimos iniciar tromboprofilaxis a todos los pacientes hospitalizados por síntomas asociados con una infección por COVID-19, a menos que esté contraindicado, con enoxaparina 40 mg SC diariamente si el clearance de creatinina es mayor a 30 ml/min.

Although the incidence is uncertain, some case reports suggest that COVID 19 infection is associated with an increased risk of venous thromboembolism. We suggest starting prophylactic anticoagulant therapy for all patients hospitalized with a symptomatic infection with COVID-19, unless contraindicated, with enoxaparin 40 mg SC daily if creatinine clearance is greater than 30 ml/min.

[Updated recommendations for venous thromboembolic prophylaxis in Argentina]. / Recomendaciones actualizadas para profilaxis de la enfermedad tromboembólica venosa en Argentina.

Venous thromboembolic disease (VTE) in hospitalized adults has high morbidity and mortality, is the origin of chronic complications and increased cost for the health system. Since the publication of recommendations for thromboprophylaxis in hospitalized patients in 2013, new alternatives and strategies have emerged, which motivated us to update our recommendations. Although there are different consensus and clinical practice guidelines, adherence to them is suboptimal. The different therapeutic alternatives for hospitalized adult patients (non-surgical, surgical non-orthopedic, with and without cancer, orthopedic an d pregnant) have been updated, paying particular attention to the drugs available in Argentina.

La enfermedad tromboembólica venosa (ETV) en adultos hospitalizados posee elevada morbimortalidad, es origen de complicaciones crónicas y determina incrementos de costos para el sistema de salud. Desde la publicación de recomendaciones de tromboprofilaxis en pacientes internados en 2013, han surgido nuevas alternativas y estrategias, que nos motivaron a actualizar nuestras recomendaciones. A pesar de que existen diferentes consensos y guías de práctica clínica la adherencia a las mismas es subóptima. Se han actualizado las diferentes alternativas terapéuticas para los adultos hospitalizados (clínicos no quirúrgicos, quirúrgicos no ortopédicos, con y sin cáncer, ortopédicos y embarazadas), poniendo particular atención en los fármacos disponibles en Argentina.

Recomendaciones actualizadas para profilaxis de la enfermedad tromboembólica venosa en Argentina / Updated recommendations for venous thromboembolic prophylaxis in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos hospitalizados posee elevada morbimortalidad, es origen de complicaciones crónicas y determina incrementos de costos para el sistema de salud. Desde la publicación de recomendaciones de tromboprofilaxis en pacientes internados en 2013, han surgido nuevas alternativas y estrategias, que nos motivaron a actualizar nuestras recomendaciones. A pesar de que existen diferentes consensos y guías de práctica clínica la adherencia a las mismas es subóptima. Se han actualizado las diferentes alternativas terapéuticas para los adultos hospitalizados (clínicos no quirúrgicos, quirúrgicos no ortopédicos, con y sin cáncer, ortopédicos y embarazadas), poniendo particular atención en los fármacos disponibles en Argentina.

Venous thromboembolic disease (VTE) in hospitalized adults has high morbidity and mortality, is the origin of chronic complications and increased cost for the health system. Since the publication of recommendations for thromboprophylaxis in hospitalized patients in 2013, new alternatives and strategies have emerged, which motivated us to update our recommendations. Although there are different consensus and clinical practice guidelines, adherence to them is suboptimal. The different therapeutic alternatives for hospitalized adult patients (non-surgical, surgical non-orthopedic, with and without cancer, orthopedic an d pregnant) have been updated, paying particular attention to the drugs available in Argentina.

Risk of venous thromboembolic disease and adequacy of prophylaxis in hospitalized patients in Argentina: a multicentric cross-sectional study.

BACKGROUND: Venous thromboembolic disease (VTE) is associated with high morbi-mortality. Adherence rate to the recommendations of antithrombotic prophylaxis guidelines (ATPG) is suboptimal. The aim of this study was to describe the adequacy of antithrombotic prophylaxis (ATP) in hospitalized patients as the initial stage of a program designed to improve physician adherence to -ATP recommendations in Argentina. METHODS: This study was a multicenter, cross-sectional study that included 28 Institutions throughout 5 provinces in Argentina. RESULTS: 1315 patients were included, 729 (55.4%) were hospitalized for medical (clinical) reasons, and 586 (44.6%) for surgical reasons. Adequate ATP was provided to 66.9% of the patients and was more frequent in surgical (71%) compared to clinical (63.6%) subjects (p < 0.001). Inadequate ATP resulted from underuse in 76.6% of the patients. Among clinical, 203 (16%) had increased bleeding risk and mechanical ATP was used infrequently. CONCLUSIONS: The adequacy of ATP was better in low VTE risk clinical and surgical patients and high VTE risk in orthopedic patients. There was worse adequacy in high risk patients (with active neoplasm) and in those with pharmacological ATP contraindications, in which the use of mechanical methods was scarce. The adequacy of ATP was greater at institutions with < 150 beds compared with larger institutions. This is the first multicentric study reporting ATP in Argentina. Understanding local characteristics of medical performance within our territory is the first step in order to develop measures for improving ATP in our environment.

[Moderate control of hyperglycemia after acute stroke in the intensive care unit]. / Control moderado de hiperglucemia luego de infarto cerebral agudo en la unidad de cuidados intensivos.

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24% diabetics) with moderate therapy and 105 (23% diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01). Patients admitted with moderate to severe neurological deficit and treated with moderate regime had a better outcome at discharge and at 30 days (NIHSS variation: high 2.1 ± 2.6 vs. 3.4 ± 3; 30 days: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). The duration of hospitalization was lower in the moderate treatment group (5.7 vs. 9.2 days, p < 0.05), with no significant difference showing in the incidence of hypoglycemia in either group. In conclusion, moderate control of blood glucose in ACVi patients relates to an improved neurological outcome in those admitted with moderate to severe neurological deficits (NIH scale = 4), with a reduced hospital stay, and no substantial increase of hypoglycemia episodes.

Control moderado de hiperglucemia luego de infarto cerebral agudo en unidad de cuidados intensivos / Moderate control of hyperglycemia after acute stroke in the intensive care unit

La hiperglucemia después de un accidente cerebrovascular isquémico (ACVi) se asocia con peor pronóstico. Se compararon retrospectivamente los efectos entre el control de la glucemia moderado (corrección a partir de 135 mg/dl) y el conservador (a partir de 200 mg/dl) en evolución neurológica, tiempo de internación y complicaciones asociadas al tratamiento de pacientes con ACVi internados en unidad de cuidados intensivos, al alta y 30 días post-egreso. Se estudiaron 208 pacientes, 103 (24% diabéticos) con tratamiento moderado y 105 (23% diabéticos) con tratamiento conservador. La glucemia media a lo largo de la internación tendió a ser menor con el tratamiento moderado sin significancia estadística (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). La diferencia fue significativa en los no diabéticos (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), siendo más pronunciada en aquellos no diabéticos con déficit neurológico moderado a grave al ingreso (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01). Los pacientes que ingresaron con déficit neurológico moderado a grave tuvieron mejor evolución al alta y a 30 días bajo tratamiento moderado (variación de NIHSS: alta 2.1 ± 2.6 vs. 3.4 ± 3; 30 días: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). La duración de la internación fue menor con tratamiento moderado (6 ± 5 vs. 9 ± 5 días; p < 0.05). No hubo diferencias significativas en la incidencia de hipoglucemias. En conclusión, el control moderado de la glucemia en pacientes con ACVi se asoció con mejor evolución neurológica en aquellos que ingresaban con déficit neurológico moderado a grave (escala de NIH = 4), y una hospitalización más corta, sin un aumento sustancial de episodios de hipoglucemia.

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24% diabetics) with moderate therapy and 105 (23% diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130±23 mg/dl; p < 0.01). Patients admitted with moderate to severe neurological deficit and treated with moderate regime had a better outcome at discharge and at 30 days (NIHSS variation: high 2.1 ± 2.6 vs. 3.4 ± 3; 30 days: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). The duration of hospitalization was lower in the moderate treatment group (5.7 vs. 9.2 days, p < 0.05), with no significant difference showing in the incidence of hypoglycemia in either group. In conclusion, moderate control of blood glucose in ACVi patients relates to an improved neurological outcome in those admitted with moderate to severe neurological deficits (NIH scale = 4), with a reduced hospital stay, and no substantial increase of hypoglycemia episodes.

Control moderado de hiperglucemia luego de infarto cerebral agudo en unidad de cuidados intensivos / Moderate control of hyperglycemia after acute stroke in the intensive care unit

La hiperglucemia después de un accidente cerebrovascular isquémico (ACVi) se asocia con peor pronóstico. Se compararon retrospectivamente los efectos entre el control de la glucemia moderado (corrección a partir de 135 mg/dl) y el conservador (a partir de 200 mg/dl) en evolución neurológica, tiempo de internación y complicaciones asociadas al tratamiento de pacientes con ACVi internados en unidad de cuidados intensivos, al alta y 30 días post-egreso. Se estudiaron 208 pacientes, 103 (24% diabéticos) con tratamiento moderado y 105 (23% diabéticos) con tratamiento conservador. La glucemia media a lo largo de la internación tendió a ser menor con el tratamiento moderado sin significancia estadística (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). La diferencia fue significativa en los no diabéticos (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), siendo más pronunciada en aquellos no diabéticos con déficit neurológico moderado a grave al ingreso (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01). Los pacientes que ingresaron con déficit neurológico moderado a grave tuvieron mejor evolución al alta y a 30 días bajo tratamiento moderado (variación de NIHSS: alta 2.1 ± 2.6 vs. 3.4 ± 3; 30 días: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). La duración de la internación fue menor con tratamiento moderado (6 ± 5 vs. 9 ± 5 días; p < 0.05). No hubo diferencias significativas en la incidencia de hipoglucemias. En conclusión, el control moderado de la glucemia en pacientes con ACVi se asoció con mejor evolución neurológica en aquellos que ingresaban con déficit neurológico moderado a grave (escala de NIH = 4), y una hospitalización más corta, sin un aumento sustancial de episodios de hipoglucemia.(AU)

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24% diabetics) with moderate therapy and 105 (23% diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130±23 mg/dl; p < 0.01). Patients admitted with moderate to severe neurological deficit and treated with moderate regime had a better outcome at discharge and at 30 days (NIHSS variation: high 2.1 ± 2.6 vs. 3.4 ± 3; 30 days: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). The duration of hospitalization was lower in the moderate treatment group (5.7 vs. 9.2 days, p < 0.05), with no significant difference showing in the incidence of hypoglycemia in either group. In conclusion, moderate control of blood glucose in ACVi patients relates to an improved neurological outcome in those admitted with moderate to severe neurological deficits (NIH scale = 4), with a reduced hospital stay, and no substantial increase of hypoglycemia episodes.(AU)

Control moderado de hiperglucemia luego de infarto cerebral agudo en la unidad de cuidados intensivos. / [Moderate control of hyperglycemia after acute stroke in the intensive care unit].

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24

diabetics) with moderate therapy and 105 (23

diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01). Patients admitted with moderate to severe neurological deficit and treated with moderate regime had a better outcome at discharge and at 30 days (NIHSS variation: high 2.1 ± 2.6 vs. 3.4 ± 3; 30 days: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). The duration of hospitalization was lower in the moderate treatment group (5.7 vs. 9.2 days, p < 0.05), with no significant difference showing in the incidence of hypoglycemia in either group. In conclusion, moderate control of blood glucose in ACVi patients relates to an improved neurological outcome in those admitted with moderate to severe neurological deficits (NIH scale = 4), with a reduced hospital stay, and no substantial increase of hypoglycemia episodes.

[Venous thromboembolic prophylaxis. Guidelines for adults in Argentina]. / Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina.

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / Venous thromboembolic prophylaxis: Guidelines for adults in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).(AU)

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).(AU)

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / Venous thromboembolic prophylaxis: Guidelines for adults in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

Cerebrospinal fluid lactate in post-neurosurgical bacterial meningitis diagnosis.

BACKGROUND: Differential diagnosis between post-neurosurgical bacterial meningitis (PNBM) and aseptic meningitis is difficult. Inflammatory and biochemical cerebrospinal fluid (CSF) changes mimic those classically observed after CNS surgery. CSF lactate assay has therefore been proposed as a useful PNBM marker. OBJECTIVE: To evaluate the diagnostic accuracy of CSF lactate as a PNBM marker in patients hospitalized after a neurosurgical procedure. METHODS: Between July 2005 and June 2009, a prospective clinical study, in which all patients with clinical suspicion of PNBM were enrolled, was conducted at our neurosurgical Intensive Care Unit. PNBM diagnosis was categorized as proven, probable or negative before the analysis. RESULTS: Seventy-nine patients, 51 males with a mean age of 50 years (range 32-68 years) were included. Surgery was elective in 76% patients, mostly for brain tumors (57%); thirty PNBM episodes were identified. CSF parameters were significantly different in glucose concentration (27 mg% vs. 73 mg%, p<0.001), lactate (8 mmol/L vs. 2.8 mmol/L, p<0.001), CSF neutrophil pleocytosis (850 mm(-3) vs. 10mm(-3), p<0.001), and protein levels (449 mg% vs. 98 mg%) between the PNBM and non-PNBM groups. The ROC curve that best fits PNBM diagnosis is lactate. CONCLUSION: Increased CSF lactate is a useful PNBM marker, with better predictive value than CSF hypoglycorrhachia or pleocytosis. Lactate levels ≥ 4 mmol/L showed 97% sensitivity and 78% specificity, with a 97% negative predictive value.

Candida: epidemiología y factores de riesgo para especies no albicans / Candida: Epidemiology and risk factors for non-albicans species

Introducción La incidencia de infecciones fúngicas nosocomiales aumentó significativamente en la última década. La detección de Candida en muestras clínicas puede representar una colonización, infección local (muguet) o infección invasiva (candidemia). Conocer las especies aisladas facilita la elección del mejor tratamiento. El objetivo de este trabajo es determinar la frecuencia y la distribución de especies de Candida spp. detectadas en muestras clínicas, analizar las características clínicas de la población involucrada y determinar los factores de riesgo para especies Candida no albicans. Métodos Estudio retrospectivo, observacional, de 2006 a 2010, que incluye las detecciones de Candida en muestras clínicas de pacientes internados al menos 48 h en un centro neurológico. Se analizaron características epidemiológicas, comorbilidades, factores de riesgo, factores asociados a la detección de especies no albicans, tratamiento antifúngico, episodios adversos y mortalidad. Resultados Se detectaron 321 Candida spp. de muestras clínicas: C. albicans 139 (43,3%) y Candida no albicans 182 (56,7%). La distribución de las muestras fue orina 122 (Candida no albicans 67,2%), vía aérea 81 y fauces 45 (C. albicans 58 y 66,6%, respectivamente), candidemia 40 (Candida no albicans 75%: C. tropicalis 11, C. parapsilosis 9). La comorbilidad más usual fue el tumor sólido (35,5%). Los factores de riesgo hallados más frecuentes fueron el tratamiento antibiótico (85,5%), el tratamiento con esteroides (61,7%) y los pacientes internados en la UCI al diagnóstico (61,6%). El análisis de los factores de riesgo y el aislamiento de Candida no albicans muestra que la quimioterapia, la cirugía previa y el tratamiento con aminopenicilinas, carbapenems y glucopéptidos fueron (..) (AU)

Introduction Nosocomial fungal infections have increased significantly in the last decade. Candida detection in clinical specimens can mean either colonization or an infection which can be local (muguet) or invasive. Knowledge of the species helps in choosing the best treatment. The aims of this study were to determine the frequency and distribution of Candida species detected in clinical samples, to analyze the clinical characteristics of the involved population and to determine the risk factors for Candida non-albicans species. Methods Retrospective, observational. Period: 2006-2010. Inclusion criteria: all isolates of Candida in clinical specimens from patients hospitalized —at least 48 hours in a neurological center. We analyzed epidemiological characteristics, co morbidities, risk factors, factors associated with Candida non-albicans detection, antifungal treatment, development of adverse events and mortality. Results Candida spp. was isolated from 321 clinical specimens: 139 (43.3%) were C. albicans and 182 (56.7%) Candida non-albicans. The distribution of the sample was: urine 122 (Candida non-albicans 67.2%), airway 81, oropharynx 45 (C. albicans) and candidemia 40 (Candida non-albicans 75%). The most frequent co-morbidity was solid tumor (35.5%). The main risk factors were antibiotic therapy (85.5%), steroid therapy (61.7%) and in ICU at diagnosis (61.6%). The analysis of risk factors and the isolation of Candida non-albicans shows that chemotherapy, previous surgery, treatment with aminopenicillins, carbapenems and glycopeptides were statistically significant (P < .05). There is a trend in neutropenic (..) (AU)

QTc prolongation after brain surgery.

OBJECTIVE: Abnormalities observed in the electrocardiogram (ECG) after acute central nervous system (CNS) events have been reported. Our objective was to assess the incidence of heart rate-corrected QT interval (QTc) prolongation in patients admitted to the intensive care unit (ICU) after brain surgery. METHODS: Admission standard 12-lead ECGs were analyzed blinded to patient data. The QT interval was measured and Bazzett's formula was used to obtain QTc. Prolonged QTc was defined as ≧450 ms. RESULTS: We included 114 patients in the study. The mean age was 49±17 years. Brain neoplasm was the surgical indication in 90% of the patients. The mean QTc was 470±42 ms. Prolonged QTc was found in 71% patients. The heart rate-corrected QT interval was between 450 ms and 500 ms in 52% and >500 ms in 19% of the patients. The heart rate and concentration of serum glucose were higher in the prolonged QTc group. Only 7·5% of all patients had hypokalemia (≤3 mEq/l). In the prolonged QTc group 9·2% had hypokalemia compared to 3·2% in normal QTc patients (P = 0·406). There were no significant associations between categories of QTc and the serum levels of creatinine, magnesium, calcium, sodium, or pH. Phenytoin and metoclopramide were not frequently used in patients with prolonged QTc. DISCUSSION: This study supports our hypothesis that prolonged QTc is frequently observed after a brain surgery. Hypokalemia, hypocalcaemia, and drugs such as metoclopramide or phenytoin could not explain the high incidence of prolonged QTc. Brain injury during a surgical procedure may be one of the primary causes of QTc prolongation after neurosurgery.

[Candida: epidemiology and risk factors for non-albicans species]. / Candida: epidemiología y factores de riesgo para especies no albicans.

INTRODUCTION: Nosocomial fungal infections have increased significantly in the last decade. Candida detection in clinical specimens can mean either colonization or an infection which can be local (muguet) or invasive. Knowledge of the species helps in choosing the best treatment. The aims of this study were to determine the frequency and distribution of Candida species detected in clinical samples, to analyze the clinical characteristics of the involved population and to determine the risk factors for Candida non-albicans species. METHODS: Retrospective, observational. PERIOD: 2006-2010. INCLUSION CRITERIA: all isolates of Candida in clinical specimens from patients hospitalized at least 48 hours in a neurological center. We analyzed epidemiological characteristics, co morbidities, risk factors, factors associated with Candida non-albicans detection, antifungal treatment, development of adverse events and mortality. RESULTS: Candida spp. was isolated from 321 clinical specimens: 139 (43.3%) were C. albicans and 182 (56.7%) Candida non-albicans. The distribution of the sample was: urine 122 (Candida non-albicans 67.2%), airway 81, oropharynx 45 (C. albicans) and candidemia 40 (Candida non-albicans 75%). The most frequent co-morbidity was solid tumor (35.5%). The main risk factors were antibiotic therapy (85.5%), steroid therapy (61.7%) and in ICU at diagnosis (61.6%). The analysis of risk factors and the isolation of Candida non-albicans shows that chemotherapy, previous surgery, treatment with aminopenicillins, carbapenems and glycopeptides were statistically significant (P<.05). There is a trend in neutropenic patients (P=.055) and in ICU at diagnosis (P=.076). Overall survival was 71%. CONCLUSIONS: Candida species distribution varies with the type of sample analyzed. Non-albicans species make up the majority of the isolates. The identification of the species involved per sample helps to optimize treatment. The high frequency of isolation of Candida in patients on steroids and antibiotics and admitted to ICU, is worth pointing out. Patients with previous surgery, treated with the aforementioned antibiotics or chemotherapy, could receive non-azole antifungals in the initial empirical treatment strategy.

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / [Venous thromboembolic prophylaxis. Guidelines for adults in Argentina].

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina. / [Venous thromboembolic prophylaxis. Guidelines for adults in Argentina].

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

Carotid endarterectomy in asymptomatic carotid stenosis: a decision analysis.

OBJECTIVES: To present a model of decision analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy and the rate of preventable future events. METHODS: We used data from a systematic review to define values for a base case and perform a sensitivity analysis. The primary endpoint was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either immediate prophylactic carotid endarterectomy or medical treatment alone. RESULTS: The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is less than 4 days over the course of 5 years. One-way sensitivity analysis demonstrated that if the perioperative rate of death or disabling stroke is greater than 2.1%, then medical treatment is better. A non-surgical strategy is also better if the risk of fatal and disabling stroke with medical treatment is less than 1.09% per year, or if the rate of fatal and disabling stroke beyond 30 days following endarterectomy is greater than 0.51% per year. CONCLUSIONS: In this model, immediate prophylactic carotid endarterectomy seems to offer a minimum net benefit in terms of fatal or disabling stroke-free survival over a 5-year period, when compared to medical treatment alone.