Sistema hospitalario en situación de crisis: implementación de sistema de comando de incidentes para enfrentar pandemia SARS-CoV-2 en Clínica Las Condes, Chile / Implementation of incident command system to deal with SARS-CoV-2 pandemic in Clínica Las Condes, Chile

La pandemia en Chile generó un desafío de modernización y gestión de los Cuidados Intensivos, haciendo necesario que las unidades de pacientes críticos realizaran un aumento de su capacidad hospitalaria, lo que requiere preparar una infraestructura, un equipamiento mínimo, protocolos y un equipo humano preparado y alineado, para garantizar la seguridad y calidad de atención a los pacientes. Una forma de lograrlo es la incorporación de la estrategia militar de Sistema de Comando de Incidentes, utilizado para enfrentar distintos tipos de desastres, con una estructura modular de comando y sus seccionales de trabajo, con diferentes equipos y líderes para hacer frentes a los variados desafíos. El objetivo de este artículo es describir la instauración del sistema de comando de incidentes en un hospital privado, detallando su conformación y los resultados logrados.

The pandemic in Chile has been a real challenge in terms of modernization and management of intensive care. Critical care units have been forced to increase their hospital capacity in terms of infrastructure, equipment, protocols and human team, while guaranteeing safety and high-quality patient care.One approach to achieve this objective is to develop the army strategy called incident command system that has been used to face different types of disaster. A modular command structure is developed based on the creation of teams each lead by an expert in different areas in order to cope with a variety of upcoming challenges.The objective of this article is to describe the setting up of a successful incident command system in a private hospital, detailing its formation and results obtained.

Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital.

OBJECTIVE: To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation. METHODS: Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates. RESULTS: The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma. CONCLUSION: Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

Traqueostomía percutánea con asistencia fibrobroncoscópica: una década de experiencia en un hospital universitario / Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

RESUMEN Objetivo: Evaluar eficacia y seguridad de la traqueostomía percutánea, mediante dilatación única con asistencia fibrobroncoscópica, en pacientes críticos sometidos a ventilación mecánica. Métodos: Entre los años 2004 y 2014, se incluyeron prospectivamente 512 enfermos consecutivos con indicación de traqueostomía según los criterios clínicos de nuestro centro. Un tercio de los pacientes fueron de alto riesgo. Se registraron variables demográficas, puntaje APACHE II, y días de ventilación mecánica previo a traqueostomía percutánea. La eficacia del procedimiento fue evaluada mediante tasa de éxito en su ejecución y necesidad de conversión a técnica abierta. La seguridad fue evaluada por tasa de complicaciones operatorias y postoperatorias. Resultados: La edad media del grupo fue 64 ± 18 años (203 mujeres y 309 varones). El puntaje APACHE II fue 21 ± 3. Los pacientes permanecieron en promedio 11 ± 3 días en ventilación mecánica antes de la realización de la traqueostomía percutánea. Todos los procedimientos se completaron exitosamente, sin necesidad de convertir a técnica abierta. Dieciocho pacientes (3,5%) presentaron complicaciones operatorias. Cinco pacientes experimentaron desaturación transitoria, cuatro presentaron hipotensión relacionada a la sedación, y nueve presentaron sangrado menor, pero ninguno requirió transfusión. No se registraron complicaciones graves, ni muertes asociadas al procedimiento. Once pacientes (2,1%) presentaron complicaciones postoperatorias. Siete presentaron sangrado menor y transitorio del estoma de la traqueostomía percutánea, 2 sufrieron desplazamiento de la cánula de traqueostomía y 2 desarrollaron infección superficial del estoma. Conclusión: La traqueostomía percutánea mediante la técnica de dilatación única con asistencia fibrobroncoscópica, parece ser efectiva y segura en enfermos críticos sometidos a ventilación mecánica, cuando es realizada por intensivistas experimentados mediante un abordaje ...

ABSTRACT Objective: To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation. Methods: Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates. Results: The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma. Conclusion: Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using ...

Central venous saturation in septic shock: co-oximetry vs gasometry.

OBJECTIVES: Central venous oxygen saturation calculated by gasometry (Gaso-Scvo2) is more available than central venous oxygen saturation measured by co-oximetry (Co-oxy-Scvo2) in environments with less resources and underdeveloped countries. Therefore, we aimed to determine the agreement between Co-oxy-Scvo2 and Gaso-Scvo2 and between central venous oxygen tension measured by gasometry (Gaso-Pcvo2) and Co-oxy-Scvo2, respectively. DESIGN AND SETTINGS: This is a prospective study in a university hospital's intensive care unit. PATIENTS: Sixteen patients were studied during the first 48 hours after diagnosis of septic shock. All patients were intubated, connected to mechanical ventilation, and resuscitated according to the standards of care. MEASUREMENTS AND RESULTS: One hundred eleven pairs of central venous blood measurements were analyzed both by conventional gasometry and co-oximetry. Bland and Altman analysis between Co-oxy-Scvo2 and Gaso-Scvo2 showed lack of agreement (1.7 [-10.7, +14.2]). A Gaso-Scvo2 less than 70% had a positive predictive value of 63% in relation to Co-oxy-Scvo2, and its negative predictive value was 90% with 20% false-positives and 5% false-negatives. The area under the receiver operator characteristic curve of Gaso-Pcvo2 to discriminate a Co-oxy-Scvo2 greater than or equal to 70% was 0.87 (confidence interval, 0.80-0.93), and the best cut-off point was a Gaso-Pcvo2 more than 40 mm Hg, (sensitivity, 75%; specificity, 93%). CONCLUSIONS: The reliability of Gaso-Scvo2 determination during the resuscitation phase of septic shock is not acceptable. There is a good agreement between a Gaso-Pcvo2 more than 40 mm Hg and a Co-oxy-Scvo2 greater than or equal to 70%. Our results suggest that given these limitations, Gaso-Scvo2 results should be interpreted with caution, helped by Gaso-Pcvo2 measurements and in context with other perfusion parameters.

High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock.

We report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team.

Hemofiltração de alto volume e ventilação em posição prona em hemorragia subaracnóidea complicada por grave síndrome do desconforto respiratório agudo e choque séptico refratário / High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock

Relatamos o tratamento bem-sucedido de dois pacientes com hemorragia subaracnóidea complicada com grave falência respiratória e choque séptico refratário, utilizando, simultaneamente, ventilação em posição prona e hemofiltração de alto volume. Esses tratamentos de resgate permitiram que os pacientes superassem a grave situação sem complicações associadas ou efeitos deletérios na pressão intracraniana e de perfusão cerebral. A ventilação em posição prona é, hoje, um tratamento aceito para síndrome de desconforto respiratório agudo grave, e a hemofiltração de alto volume é um suporte hemodinâmico não convencional, que tem diversos mecanismos potenciais para melhorar o choque séptico. Neste artigo revisamos brevemente esses tratamentos e as evidências relacionadas. Quando outras terapias convencionais são insuficientes para proporcionar oxigenação e perfusão como parte do cuidado neuroprotetor básico dentro de limites seguros em pacientes com hemorragia subaracnóidea, esses tratamentos de resgate podem ser considerados caso a caso por uma equipe com experiência em cuidados críticos.

We report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team.

Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome.

RATIONALE: Positive end-expiratory pressure (PEEP) and prone positioning may induce lung recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether there is interdependence between the effects of PEEP and prone positioning on these variables is unknown. OBJECTIVES: To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung recruitability. METHODS: Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively. MEASUREMENTS AND MAIN RESULTS: Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue (501 ± 201 to 322 ± 132 grams; P < 0.001) and increased tidal-hyperinflation (0.41 ± 0.26 to 0.57 ± 0.30%; P = 0.004) in supine. Prone positioning further decreased nonaerated tissue (322 ± 132 to 290 ± 141 grams; P = 0.028) and reduced tidal hyperinflation observed at PEEP 15 in supine patients (0.57 ± 0.30 to 0.41 ± 0.22%). Cyclic recruitment/de-recruitment only decreased when high PEEP and prone positioning were applied together (4.1 ± 1.9 to 2.9 ± 0.9%; P = 0.003), particularly in patients with high lung recruitability. CONCLUSIONS: Prone positioning enhances lung recruitment and decreases alveolar instability and hyperinflation observed at high PEEP in patients with ARDS.

Higher than recommended amikacin loading doses achieve pharmacokinetic targets without associated toxicity.

Antibiotic therapy improves the outcome of severe sepsis and septic shock, however pharmacokinetic properties are altered in this scenario. Amikacin (AMK) is an option to treat community or nosocomial infections, although standard doses might be insufficient in critically ill patients. The aim of this study was to evaluate two AMK dosage regimens in comparison with standard therapy with regard to efficacy in achieving adequate plasma levels as well as safety. In total, 99 patients with severe sepsis or septic shock were randomised to different AMK dose protocols: Group 1, 25 mg/kg/day; Group 2, 30 mg/kg/day; and Group 3, historical standard dose (15 mg/kg/day). Peak plasma concentrations at 1 h (C(max)) were determined. Pharmacokinetics was determined and renal function was monitored to evaluate toxicity. Groups were compared using bilateral T-test. Demographic characteristics of the three groups were comparable. AMK C(max) values were 57.4±9.8, 72.1±18.4 and 35.2±9.4 µg/mL, respectively (P<0.001 between Groups 1 and 2 versus Group 3, and P<0.01 between Group 1 versus Group 2). A C(max)>60 µg/mL was reached by 39%, 76% and 0% of patients in Groups 1, 2 and 3, respectively (P<0.001) and creatinine clearance at Day 28 was 95.6±47.4, 89.7±26.6 and 56.4±18.4 mL/min, respectively. In conclusion, a 30 mg/kg daily dose of AMK presents significantly higher C(max) compared with the other groups, with 76% of patients reaching recommended peak plasma levels with no association with higher nephrotoxicity. Standard doses are insufficient in critically ill patients to reach the recommended C(max).

Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza.

The authors describe two cases that developed organizing pneumonia (OP) associated with novel influenza A(H1N1) virus. These patients were admitted to intensive care unit (ICU) because of severe respiratory failure. After initial clinical improvement, both patients worsened their condition during their second week of ICU stay, presenting fever, increasing in inflammatory parameters and worsening in oxygen exchange and respiratory mechanics. Chest x-rays and computed tomographies showed an increment on lung infiltrates, given by areas of consolidation and ground glass opacification. Although broad-spectrum antibiotics were administered, patients showed no improvement. All cultures, including bronchoalveolar lavage samples, were negative. In both cases, an open lung biopsy was performed, and histopathological examination of the specimen was compatible with OP. Both patients were successfully treated with high-dose corticoids. The aim of this report is to alert about the possibility of OP associated with novel influenza virus in patients with severe respiratory failure.

[Prolonged prone position ventilation for severe respiratory distress syndrome post-pneumonectomy. Report of one case]. / Ventilación en posición prono prolongada como alternativa en el tratamiento del síndrome de distrés respiratorio agudo grave posneumonectomía. Caso clínico.

Management of patients with severe respiratory failure is mainly supportive, and protective mechanical ventilation is the pivotal treatment. When conventional therapy is insufficient to improve oxygenation without deleterious effects, other strategies should be considered. We report a 53 year-old male who presented a severe respiratory failure refractory to conventional management after pneumonectomy. Prone position ventilation was used for 36 hours. Respiratory variables improved and he did not show hemodynamic instability. He was returned to the supine position without worsening of oxygenation parameters. Extended prone position ventilation could be considered in patients presenting with unresponsive severe respiratory failure after pulmonary resection.

Ventilación en posición prono prolongada como alternativa en el tratamiento del síndrome de distrés respiratorio agudo grave posneumonectomía: Caso clínico / Prolonged prone position ventilation for severe respiratory distress syndrome post-pneumonectomy: Report of one case

Management of patients with severe respiratory failure is mainly supportive, and protective mechanical ventilation is the pivotal treatment. When conventional therapy is insufficient to improve oxygenation without deleterious effects, other strategies should be considered. We report a 53 year-old male who presented a severe respiratory failure refractory to conventional management after pneumonectomy. Prone position ventilation was used for 36 hours. Respiratory variables improved and he did not show hemodynamic instability. He was returned to the supine position without worsening of oxygenation parameters. Extended prone position ventilation could be considered in patients presenting with unresponsive severe respiratory failure after pulmonary resection.

Evaluación de la sobrevida a largo plazo del carcinoide del apéndice cecal. Un análisis a partir de 8.903 apendicectomías / Long-term survival in carcionoid tumour of the appendix. An analysis of 8903 appendectomies

IntroducciónEl tumor del apéndice cecal más frecuente es el carcinoide y en la mayoría de los enfermos es un hallazgo del estudio anatomopatológico. Los objetivos de este trabajo son analizar las características clínicas y anatomopatológicas, el tratamiento quirúrgico y la sobrevida a largo plazo de una serie de pacientes con un tumor carcinoide apendicular.Material y métodosEstudio retrospectivo de pacientes con diagnóstico anatomopatológico de carcinoide apendicular tratados entre 1980 y 2007. Se analizaron las características clínicas, el estudio anatomopatológico, el tratamiento quirúrgico y la sobrevida alejada.ResultadosDurante este período se realizaron 8.903 apendicectomías y a 40 pacientes (0,44%) se les diagnosticó un carcinoide apendicular: 25 mujeres y 15 varones con una edad de 37±18 años. En 33 enfermos la cirugía se realizó por sospecha de apendicitis aguda, la que se confirmó en 24 de ellos. El tumor se ubicó en el tercio distal del apéndice en 24 pacientes (60%) y en 28 enfermos (70%), y midió 1cm o menos. Veintinueve (72,5%) de estos tumores infiltraron la subserosa o la serosa. A 3 enfermos se les realizó una hemicolectomía derecha complementaria y en ninguno de ellos se observó afectación ganglionar. El tiempo de seguimiento promedio fue 81,2 meses. La sobrevida a 5 años de la serie fue del 97,5%.ConclusionesEl diagnóstico de un carcinoide apendicular en la mayoría de los enfermos es un hallazgo en pacientes operados por sospecha de apendicitis aguda. La mayoría de los enfermos logra una sobrevida prolongada sólo con la apendicectomía(AU)

IntroductionAppendiceal carcinoids are the most frequent tumors of the appendix and are usually detected as an incidental finding in the final pathology report. The aim of this study was to evaluate the clinical and pathological characteristics, surgical treatment and long-term survival in patients with an appendiceal carcinoid tumor.Material and methodsWe performed a retrospective study of patients treated from 1980 to 2007 with a pathological diagnosis of appendiceal carcinoid tumor. In all patients, clinical and pathological characteristics, surgical treatment and long-term survival were evaluated.ResultsIn this period, 8903 appendectomies were performed. Carcinoid tumor was diagnosed in 40 patients (25 women and 15 men), aged 37±18 years old. The appendectomy was performed for appendicitis in 33 of these patients, and the final pathology report confirmed the diagnosis in 24. The tumor was localized in the distal third of the appendix in 24 patients (60%), and the size of the tumor was less than 1cm in 28 (70%). Twenty-nine (72.5%) of these tumors infiltrated the subserosal and/or the serosal layer. Three patients were treated with a complementary right colectomy and none had lymph node compromise. The mean follow-up was 81.2 months. The overall 5- year survival was 97.5%.ConclusionsAppendiceal carcinoid tumor is usually detected incidentally in the pathological analysis in patients undergoing surgery for suspected appendicitis. Long-term survival is high with appendectomy alone(AU)

[Long-term survival in carcinoid tumour of the appendix. An analysis of 8903 appendectomies]. / Evaluación de la sobrevida a largo plazo del carcinoide del apéndice cecal. Un análisis a partir de 8.903 apendicectomías.

INTRODUCTION: Appendiceal carcinoids are the most frequent tumors of the appendix and are usually detected as an incidental finding in the final pathology report. The aim of this study was to evaluate the clinical and pathological characteristics, surgical treatment and long-term survival in patients with an appendiceal carcinoid tumor. MATERIAL AND METHODS: We performed a retrospective study of patients treated from 1980 to 2007 with a pathological diagnosis of appendiceal carcinoid tumor. In all patients, clinical and pathological characteristics, surgical treatment and long-term survival were evaluated. RESULTS: In this period, 8903 appendectomies were performed. Carcinoid tumor was diagnosed in 40 patients (25 women and 15 men), aged 37+/-18 years old. The appendectomy was performed for appendicitis in 33 of these patients, and the final pathology report confirmed the diagnosis in 24. The tumor was localized in the distal third of the appendix in 24 patients (60%), and the size of the tumor was less than 1cm in 28 (70%). Twenty-nine (72.5%) of these tumors infiltrated the subserosal and/or the serosal layer. Three patients were treated with a complementary right colectomy and none had lymph node compromise. The mean follow-up was 81.2 months. The overall 5- year survival was 97.5%. CONCLUSIONS: Appendiceal carcinoid tumor is usually detected incidentally in the pathological analysis in patients undergoing surgery for suspected appendicitis. Long-term survival is high with appendectomy alone.

Extended prone position ventilation in severe acute respiratory distress syndrome: a pilot feasibility study.

OBJECTIVES: The aim of the study was to evaluate the safety of extended prone position ventilation (PPV) and its impact on respiratory function in patients with severe acute respiratory distress syndrome (ARDS). DESIGN: This was a prospective interventional study. SETTING: Patients were recruited from a mixed medical-surgical intensive care unit in a university hospital. PATIENTS: Fifteen consecutive patients with severe ARDS, previously unresponsive to positive end-expiratory pressure adjustment, were treated with PPV. INTERVENTION: Prone position ventilation for 48 hours or until the oxygenation index was 10 or less (extended PPV). RESULTS: The elapsed time from the initiation of mechanical ventilation to pronation was 35 +/- 11 hours. Prone position ventilation was continuously maintained for 55 +/- 7 hours. Two patients developed grade II pressure ulcers of small extent. None of the patients experienced life-threatening complications or hemodynamic instability during the procedure. The patients showed a statistically significant improvement in Pao(2)/Fio(2) (92 +/- 12 vs 227 +/- 43, P < .0001) and oxygenation index (22 +/- 5 vs 8 +/- 2, P < .0001), reduction of PaCo(2) (54 +/- 9 vs 39 +/- 4, P < .0001) and plateau pressure (32 +/- 2 vs 27 +/- 3, P < .0001), and increment of the static compliance (21 +/- 3 vs 37 +/- 6, P < .0001) with extended PPV. All the parameters continued to improve significantly while they remained in prone position and did not change upon returning the patients to the supine position. CONCLUSIONS: The results obtained suggest that extended PPV is safe and effective in patients with severe ARDS when it is carried out by a trained staff and within an established protocol. Extended PPV is emerging as an effective therapy in the rescue of patients from severe ARDS.

Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study.

BACKGROUND: Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy. OBJECTIVE: The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients. PATIENTS AND METHOD: A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m(2). RESULTS: The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 +/- 9 kg/m(2) vs 22 +/- 3 kg/m(2) for the nonobese patient group (P < .001). The obese patients required 18 +/- 7 days of mechanical ventilation, on average, before PT vs 16 +/- 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2). CONCLUSION: Percutaneous tracheostomy using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock.

PURPOSE: The objective of this article is to study the cumulative incidence of intra-abdominal hypertension (IAH) in septic shock (SS) patients during the first 72 hours of intensive care unit (ICU) admission and to determine if the presence and severity of IAH are associated with sepsis morbidity and mortality. MATERIALS AND METHODS: Eighty-one consecutive SS patients admitted to a surgical-medical ICU of an academic university hospital (January 2005 to January 2006) were included. Intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) were measured every 6 h (intermittently) for 72 h. Intra-abdominal pressure was registered as minimal, mean, and maximal values per day, during shock and throughout the study period. Intra-abdominal hypertension was diagnosed if IAP remained 12 mm Hg or higher on 2 consecutive measurements and stratified according to the most recent consensus definition (www.wsacs.org). RESULTS: According to maximal and mean IAP values, 67 (82.7%) and 62 (76.5%) of the patients developed IAH during the study period, respectively. Mean IAP values remained stable throughout the study period. Surgical patients had a higher incidence of IAH than medical patients (93% vs 73%, P < .009). Maximal IAPs were normally distributed, with nonsurvivors exhibiting significantly higher IAP levels during shock (survivors, 17.2 +/- 5.3; nonsurvivors, 19.9 +/- 5.6 mm Hg; P < .04). Patients with IAH exhibited significantly lower values of APP and diuresis, higher values of lactate and creatinine, and higher maximal norepinephrine doses, and were more frequently mechanically ventilated (P < .05 for all). Increasing degrees of IAH and the development of the abdominal compartment syndrome were associated with lower APP and higher maximal serum creatinine levels (P < .03 for both). CONCLUSIONS: Septic shock patients have a very high incidence of IAH, which seems to be associated with the severity of shock and could be related to the development of organ dysfunctions, particularly renal dysfunction. Intra-abdominal pressure should be routinely monitored during the course of SS.

Cervical metastases of glucagonoma in a patient with multiple endocrine neoplasia type 1: report of a case.

Multiple endocrine neoplasia type 1 (MEN 1) is a syndrome characterized by tumors of the parathyroid glands, pancreatic islet cells, duodenum, and pituitary gland. We report a case of cervical metastases of glucagonoma with MEN 1. The patient was a 34-year-old woman admitted to our hospital with epigastric pain. Her medical history included two resections of prolactinoma and two upper GI hemorrhages secondary to duodenal ulcers. Computed tomography (CT) showed two hypervascular lesions in the tail of the pancreas and cervical ultrasound showed multiple hypoechogenic ovoid images in the neck. A cervical CT scan confirmed two 15-mm lymph nodes in the left cervical region and 111In-DOTATOC imaging showed focal abnormal somatostatin expression in the pancreatic tail and the cervical nodes. The patient had asymptomatic hypoglycemic episodes, with blood sugar levels as low as 30 mg/dl, which raised our suspicion of MEN 1 associated with pancreatic insulinoma. Thus, we performed a distal pancreatectomy with bilateral cervical dissection and parathyroid gland resection. Histopathological examination revealed 12 pancreatic tumors as well as metastases in four cervical lymph nodes. The resected parathyroid glands had normal structure, suggesting parathyroid hyperplasia. A follow-up CT scan, 18 months after surgery, showed new tumors in the head of the pancreas and in the duodenal wall. A pancreatoduodenectomy was performed and histopathological examination revealed nine nonfunctioning endocrine tumors in the pancreas, one tumor in the duodenal wall, and metastases in two peripancreatic lymph nodes. The patient recovered well and remains asymptomatic.

Sobrevida alejada de pacientes operados por cáncer gástrico incipiente / Long term survival of patients operated for early gastric cancer

Background: Early gastric cancer involves mucosa and submucosa, independent of lymph node involvement. Radical gastrectomy is the standard treatment. Aim: To assess long term survival of patients operated for an early gastric cancer. Material and methods: Retrospective Rev iew of medical and pathology records of patients subjected to a gastrectomy for an early gastric cancer, between 1975 and 2002. All were treated using a standardized protocol and staged according to 2002 TNM classification of the American Joint Committee of Cáncer (AJCC). Demographic and pathologic features, operation performed and long term survival were recorded. Survival was analyzed using Kaplan-Meier method. Results: The series is comprised by 64 males and 41 females aged 61 + 1 years. Tumor was located in the upper third of the stomach on 33 subjects and a total gastrectomy was performed in 53. Pathology showed an intestinal type adenocarcinoma in 82 and a diffuse type in 23. In patients with involvement of mucosa and submucosa, 24 ± 14 and 22 ± 14 lymph nodes were excised, respectively. Lymph node involvement was present in 8 percent and 22 percent of patients with involvement of mucosa and submucosa, respectively. Five years survival was 94 percent and 78 percent in patients without and with lymph node involvement, respectively. Survival among patients in stage IA and IB was 94 percent and 76 percent, respectively. Multivariate analysis showed that the lymph node involvement was an independent mortality risk factor. Conclusions: Total gastrectomy in patients with early gastric cancer is associated with a good survival. Lymph node involvement is a mortality risk factor.