Bloqueo subdural como complicación de la anestesia epidural / Subdural block as a complication of epidural anesthesia

El bloqueo subdural involuntario es una rara pero conocida complicación. Describimos el caso de un bloqueo subdural ocurrido al intentar realizar una analgesia epidural para el parto. (AU)

Unintentional subdural block is a rare but known complication. We describe the case of unintentional subdural block while attempting to perform an epidural block for delivery. (AU)

Insuficiencia respiratoria aguda como forma de debut de una anomalía congénita (doble arco aórtico) / Acute respiratory failure as a form of debut of a congenital anomaly (double aortic arch)

El doble arco aórtico es una anomalía vascular poco frecuente que provoca compresión traqueal y esofágica, habitualmente en losprimeros meses de vida. La estenosis traqueal asociada con el doble arco aórtico conlleva un alto riesgo de morbilidad, mortalidady reestenosis. Presentamos el caso de un paciente en que su anomalía no fue diagnosticada, y permaneció en silencio hasta la edad adulta cuando comenzó a padecer clínica compresiva. (AU)

The double aortic arch is a rare vascular anomaly that usually causes tracheal and esophageal compression in the first months oflife. Tracheal stenosis associated with double aortic arch carries a high risk of morbidity, mortality, and restenosis. We present thecase of a patient in whom his anomaly was not diagnosed, and he remained silent until adulthood when he began to suffer from compression symptoms. (AU)

Aplicaciones de la dexmetomidina en anestesia y cirugía / Application of dexmedetomidina in anesthesia and surgery

La dexmedetomidina es un potente agonista de los a-2 adrenorreceptores con propiedades simpaticolíticas, sedantes, amnésicas yanalgésicas, que se ha descrito como un complemento útil y seguro en muchas aplicaciones clínicas, incluyendo sedación en Cuidados Intensivos, anestesia regional y general, sedación en proceso pediátricos e intubación con fibrobroncoscopio en el paciente despierto. Revisamos la aplicación de la dexmedetomidina en anestesia y cirugía. (AU)

Dexmetomidine is a potent and highly seletive a-2 adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties, which has been described as a useful and safe adjunct in many clinical applications, including sedation at Intensive Care Unit, regional and general anesthesia, sedation for pediatric procedures, and awake fiber-optic intubation. We review theapplication of dexmedetomidina in anesthesia and surgery. (AU)

Anestesia regional intravenosa en antebrazo con ropivacaina, ketamina y ketorolaco / Forearm intravenous regional anesthesia with ropivacaine, ketamine and ketorolac

La anestesia regional intravenosa (ARIV) es un método fiable, simple y costo-efectivo de administrar anestesia para procedimientos quirúrgicos menores de las extremidades. Las limitaciones de este bloqueo incluyen dolor con el torniquete, corta duración del bloqueo y ausencia de analgesia postoperatoria. Para mitigar estos efectos y mejorar la calidad del bloqueo se han añadido varios fármacos a los anestésicos locales. Presentamos el caso de un paciente con enfermedad de Dupuytren con quien utilizamos anestésicos locales de larga duración (ropivacaina) y dos adjuvantes (ketamina y ketorolaco) con el fin de mejorar la anestesia operatoria y prolongar la duración de la analgesia perioperatoria

Intravenous regional anesthesia (IVRA) is known to be a reliable, simple and a cost-effective method of providing anesthesia for minor surgical procedures to the extremities. Limitation of this block include tourniquet dolor, short duration of block and absence of post-operative analgesia. To mitigate these effects and improve the quality of the block various drugs have been added to local anesthetiscs. We present the case of a patient with Dupuytren's disease in which we ropivacaine and tow adjuncts (ketamine and ketorolaco) in terms of improving the operative anesthesia and get longer lasting perioperative analgesia

Initial management of pneumonia and sepsis: factors associated with improved outcome.

Processes of care and adherence to guidelines have been associated with improved survival in community-acquired pneumonia (CAP). In sepsis, bundles of processes of care have also increased survival. We aimed to audit compliance with guideline-recommended processes of care and its impact on outcome in hospitalised CAP patients with sepsis. We prospectively studied 4,137 patients hospitalised with CAP in 13 hospitals. The processes of care evaluated were adherence to antibiotic prescription guidelines, first dose within 6 h and oxygen assessment. Outcome measures were mortality and length of stay (LOS). Oxygen assessment was measured in 3,745 (90.5%) patients; 3,024 (73.1%) patients received antibiotics according to guidelines and 3,053 (73.8%) received antibiotics within 6 h. In CAP patients with sepsis, the strongest independent factor for survival was antibiotic adherence (OR 0.4). In severe sepsis, only compliance to antibiotic adherence plus first dose within 6 h was associated with lower mortality (OR 0.60), adjusted for fine prognostic scale and hospital. Antibiotic adherence was related to shorter hospital stay. In sepsis, antibiotic adherence is the strongest protective factor of care associated with survival and LOS. In severe sepsis, combined antibiotic adherence and first dose within 6 h may reduce mortality.

[Detection of latent tuberculosis infection in peritoneal dialysis patients: new methods]. / Detección de la infección tuberculosa latente en pacientes en diálisis peritoneal: Nuevos métodos.

OBJECTIVE: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferon-gamma have been developed. The aim of this study was to evaluate if Quantiferon® TB-gold In Tube (QFT-GIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). PATIENTS AND METHODS: Fifty-four patients on PD were included in the study. They were evaluated for latent tuberculosis with QFT-GIT, TST and an assessment by an expert pulmonologist using patient's medical history and x-rays. Agreement between test results was determined. RESULTS: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest x-ray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFT-GIT and TST was fair (k=0.36; P=.006), as it was between TST and expert physician's evaluation (k=0.257; P=.06). CONCLUSIONS: According to our experience QFT-GIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST.

Detección de la infección tuberculosa latente en pacientes en diálisis peritoneal: Nuevos métodos / Detection of latent tuberculosis infection in peritoneal dialysis patients: new methods

Introducción: El riesgo de tuberculosis (TB) está aumentado en pacientes con insuficiencia renal crónica y en diálisis. La prueba de la tuberculina (PT) es el test de cribado clásico en estos pacientes, a pesar de su baja sensibilidad. En los últimos años se han desarrollado nuevos métodos diagnósticos que se basan en la producción de interferón gamma tras la estimulación con antígenos de M. tuberculosis. El objetivo de este estudio fue evaluar si el Quantiferon® TB–gold In Tube (QFT–GIT) puede contribuir en el diagnóstico de la infección tuberculosa en pacientes en diálisis peritoneal (DP). Pacientes y métodos: Se incluyeron 54 pacientes en DP. Se valoró la posibilidad de infección tuberculosa latente mediante el QFT–GIT, la PT y la valoración clinicorradiológica por parte de un neumólogo experto. Se estudiaron las concordancias entre los tests. Resultados: La prevalencia de un resultado positivo para el test de la tuberculina fue del 29,6% para el primer test y del 31,5% para el segundo (valorando el efecto booster). Una radiografía de tórax positiva aumentaba la detección de infección tuberculosa latente hasta un 42,6% y la del neumólogo hasta un 44,4%. El nivel de correlación entre el QFT–GIT y la PT fue moderado (kappa = 0,36; p = 0,006), al igual que entre la PT y la valoración del neumólogo (kappa = 0,257, p = 0,06). Conclusiones: El QFT–GIT aporta algunas ventajas en el diagnóstico de la infección tuberculosa en pacientes con insuficiencia renal crónica en DP, y puede complementar a la prueba de la tuberculina (AU)

Objective: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferon–gamma have been developed. The aim of this study was to evaluate if Quantiferon® TB–gold In Tube (QFT–GIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). Patients and methods: Fifty–four patients on PD were included in the study. They were evaluated for latent tuberculosis with QFT–GIT, TST and an assessment by an expert pulmonologist using patient's medical history and x–rays. Agreement between test results was determined. Results: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest x–ray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFT–GIT and TST was fair (ê=0.36; P=.006), as it was between TST and expert physician's evaluation (ê=0.257; P=.06). Conclusions: According to our experience QFT–GIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST (AU)

Bacteraemic pneumococcal pneumonia in COPD patients: better outcomes than expected.

The purpose of the study was to compare the clinical characteristics and outcomes of bacteraemic pneumococcal pneumonia (BPP) in chronic obstructive pulmonary disease (COPD) and non-COPD patients. A case-control study was conducted. Cases were any adult with BPP and forced expiratory volume in 1 second (FEV(1)) <80% and FEV(1)/forced expiratory vital capacity (FVC) <70%. Controls were patients with BPP without clinical diagnosis of COPD matched 1:2 by age, gender and date of isolation. Variables included co-morbidities, serotypes, pneumonia severity index (PSI), treatment and mortality. There were 45 cases and 90 controls. No significant differences were found in Charlson scores, antibiotic treatment, serotype distribution and severity. Malignancy, shock and mechanical ventilation were less frequent in COPD patients. One patient died vs 14 controls (p = 0.02). In univariate analysis, shock, multilobar involvement, Charlson score, heart failure and absence of COPD were associated with mortality. After adjustment for the presence of shock there were no differences in mortality. BPP presents less frequently with shock and has a lower mortality rate in COPD patients than in non-COPD patients.

Community-acquired pneumonia in patients with and without chronic obstructive pulmonary disease.

PURPOSE: The purpose of this study was to analyse the possible differences, especially those regarding mortality, between patients hospitalized for community-acquired pneumonia (CAP) with and without chronic obstructive pulmonary disease (COPD), and the risk factors related to mortality in the COPD group. METHODS: 710 patients with CAP were included in a prospective multicenter observational study. 244 of the patients had COPD confirmed by spirometry. RESULTS: COPD was associated with mortality in patients with CAP (OR=2.62 CI: 1.08-6.39). Patients with COPD and CAP had a significantly higher 30-day mortality rate as compared to patients without COPD. Multivariate analysis showed that PaO(2)< or =60 mmHg (OR=7.95; 95% CI: 3.40-27.5), PaCO(2)> or =45 mmHg (OR=4.6; CI: 2.3-15.1); respiratory rate > or =30/min (OR=12.25; CI: 3.45-35.57), pleural effusion (OR=8.6; 95% CI: 2.01-24.7), septic shock (OR=12.6; 95% CI: 3.4-45.66) and renal failure (OR=13.4; 95% CI: 3.2-37.8) were significantly related to mortality. Purulent sputum and fever were considered as protective factors. CONCLUSIONS: COPD was an independent risk factor for mortality in patients with CAP. Hypoxemia and hypercapnia are associated with mortality in patients with CAP with and without COPD. Chronic obstructive pulmonary disease and PaCO(2) value could be useful prognostic factors and should be incorporated in risk stratification in patients with CAP.

Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.

BACKGROUND: An inadequate response to initial empirical treatment of community acquired pneumonia (CAP) represents a challenge for clinicians and requires early identification and intervention. A study was undertaken to quantify the incidence of failure of empirical treatment in CAP, to identify risk factors for treatment failure, and to determine the implications of treatment failure on the outcome. METHODS: A prospective multicentre cohort study was performed in 1424 hospitalised patients from 15 hospitals. Early treatment failure (<72 hours), late treatment failure, and in-hospital mortality were recorded. RESULTS: Treatment failure occurred in 215 patients (15.1%): 134 early failure (62.3%) and 81 late failure (37.7%). The causes were infectious in 86 patients (40%), non-infectious in 34 (15.8%), and undetermined in 95. The independent risk factors associated with treatment failure in a stepwise logistic regression analysis were liver disease, pneumonia risk class, leucopenia, multilobar CAP, pleural effusion, and radiological signs of cavitation. Independent factors associated with a lower risk of treatment failure were influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease (COPD). Mortality was significantly higher in patients with treatment failure (25% v 2%). Failure of empirical treatment increased the mortality of CAP 11-fold after adjustment for risk class. CONCLUSIONS: Although these findings need to be confirmed by randomised studies, they suggest possible interventions to decrease mortality due to CAP.

Clinical characteristics and response to newer quinolones in Legionella pneumonia: a report of 28 cases.

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

Tuberculosis en el paciente VIH+: revisión de la clínica, diagnóstico y tratamiento en la era Haart / Tuberculosis in HIV+ patients: clinical, diagnostic and treatment revision in the Haart era

El VIH ha sido uno de los factores más importantes para el resurgimiento de la tuberculosis en todo el mundo en los años 80 y 90. La progresiva afectación del sistema inmunitario provocado por el VIH aumenta varias veces el riesgo de desarrollar una tuberculosis con coinfectados. Además el VIH altera la patogénesis de la tuberculosis cursando con formas extrapulmonares y patrones radiológicos atípicos que plantean presentaciones clínicas diferentes de las habituales (sobre todo en los casos de inmunodepresión severa). A partir de 1997 con la introducción de los nuevos antirretrovirales y la generalización de la triple terapia se ha modificado la historia natural de la enfermedad con un importante descenso de la mortalidad y de las infecciones oportunistas. El tratamiento y control de los pacientes VIH+ que presentan una tuberculosis es complejo debido a las interacciones medicamentosas entre las rifamicinas y algunos antirretrovirales. En este artículo vamos a revisar los últimos datos sobre el tratamiento de la infección tuberculosa latente y la enfermedad tuberculosa en el VIH y cuales son las pautas reconmendadas dependiendo de los distintos tratamientos antirretrovirales que nos podemos encontrar en la práctica clínica (AU)

[Community-acquired pneumonia (CAP) with hospital treatment. The value of the clinical picture and complementary exams in predicting its etiology]. / Neumonía adquirida en la comunidad (NAC) con tratamiento hospitalario. Interés de la clínica y exámenes complementarios en la predicción de la etiología.

We studied 162 patients with community-acquired pneumonia admitted for hospital treatment, in order to determine the utility of clinical and ancillary examinations for predicting etiology and guiding the most appropriate empirical treatment. Acute first appearance of symptoms, purulent expectoration, chest sounds indicating lung condensation, pleuritic chest pain and leukocytosis over 12,500/ml were statistically significant in differentiating typical pneumonias from those with atypical behavior patterns. The last two features were the most relevant according to multivariate analysis. We conclude that careful taking of case histories and basic blood testing continue to be relevant and must not be considered anachronistic for the differential diagnosis of community-acquired pneumonias.

Adenosine deaminase activity in the aetiological diagnosis of community-acquired pneumonia.

A prospective study was undertaken to assess the usefulness of serum adenosine deaminase (ADA) activity in the aetiological diagnosis of 75 patients (mean age 58 years) with community-acquired pneumonia who required hospitalization. Measurements of ADA were also carried out in 35 healthy subjects (mean age 52 years). The serum ADA activity in patients with typical bacterial pneumonia (TBP) was 21 +/- 7 IU/l and in controls 22 +/- 9 IU/l. In 43 patients with atypical pneumonia (AP), ADA levels (43 +/- 23 IU/l) were significantly higher than in the previously related groups (p < 0.001). Analysis within the group of atypical pneumonia showed significant differences for infections caused by Coxiella burnetii (61 +/- 19 IU/l, p < 0.001), Mycoplasma pneumoniae (44 +/- 26 IU/l, p < 0.001) and Legionella pneumophila (39 +/- 15 IU/l, p < 0.05), as compared with patients with bacterial pneumonia and normal control subjects. We conclude that serum ADA in patients with community-acquired pneumonia requiring hospitalization may provide useful additional diagnostic information on the aetiology of pulmonary infection.