Prevención de la insuficiencia renal aguda en el paciente crítico / Prevention of acute renal failure in critical patient

Chronic renal insufficiency (CRI) is common in chronic patients (6 to 23 percent incidence), with a 50 to 70 percent mortality rate which can reach 100 percent when this involves a multiple more than five organ failure. For practical purposes, CRI is classified into prerenal, renal, and postrenal. Knowledge of physiopathological fundamentals and diagnostic elements allows us to take adequate measures to preserve renal function. This article revises renal function protective measures against the principle causes of CRI in chronic patients: ischemic and toxic CRI, i.e. contrast agents, pigments, anfotericine, and aminoglycosides. in ischemic CRI we analyse the key factors in renal perfusion, highlighting the importance of replenishing extracelular volume, and the benefits of using norepinefrine in septic shock. The renal effect of other vasoactive and inotropic drugs such as epinephrine, dobutamine, milrinone, and dopexamine are revised, highlighting the absence of clinical evidence that supports the use of dopamine as a renal function protector. Renal actions and possible favorable effects of diuretic manitol and furosemide are analysed. In toxic CRI, we analyse the beneficial effect of fluids and the use of specific measures such as alkalinization of urine, the use of acetylcysteine, liposomal anfotericine, and single dose aminoglycosides

Síndrome de respuesta inflamatoria sistémica severa: ¿es comparable a la sepsis severa? / Systemic inflammatory response syndrome: is it similar to severe sepsis?

Background: in 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions. Aim: to evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS. Patients and methods: five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient. Results: One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48 percent in sepsis compared to 43 and 51 percent in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group. Conclusions: The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies

Oxigenación extracorpórea de membrana en síndrome de distrés respiratorio del adulto: experiencia en 2 pacientes / Extracorporeal oxygenation of membrane in adult distress respiratory syndrome: experience in 2 patients

We report 2 female patients with adult respiratory distress syndrome and severe respiratory failure in whom extracorporeal membrane oxygenation was used. Its indication was due to a bad response to conventional tretament with mechanical ventilation and high levels of positive end expiratory pressure. A 2.0 or 2.2 m2 membrane oxygenator in a veno-venous circuit with systemic anticoagulation was used, maintaining mechanical ventilation. In the first patient, the procedure was done early and was succesful, increasing hemoglobin saturation from 39 to 87 percent. The patient was withdrawn from the procedure 48 hours later and died one week later due to a septic shock. The second patient was connected to the procedure after three weeks of respiratory distress syndrome and no increase in arterial oxygenation was achieved. The patient died due to an intracraneal hemorrhage, probably hastened by systemic anticoagulation. The real benefits of extracorporeal membrane oxygenation are not defined yet