Estado ácido-base en obstetricia crítica y altitud / Acid-base status in critical care obstetrics at altitude

OBJETIVO: describir el estado ácido base en pacientes obstétricas críticamente enfermas a muy alta altitud, al momento de su ingreso a la Unidad de Cuidados Intensivos. MATERIAL Y MÉTODO: estudio descriptivo transversal. Se incluyen todas las pacientes obstétricas internadas en la Unidad de Cuidados Intensivos Adultos del Hospital del Norte de la ciudad de El Alto, La Paz a 4150 metros sobre el nivel del mar, ingresadas en el periodo enero 2019-enero 2022. RESULTADOS: se ingresaron 79 pacientes, con media de edad de 29 años (desviación estándar 8.06 años), 52 casos (66%) por preeclampsia severa, 14 casos (18%) por hemorragia obstétrica, 8 casos (10%) por sepsis obstétrica y 5 (6%) por diagnósticos diversos como taquicardia supraventricular e intoxicaciones, existieron 8 pacientes fallecidas (10% de mortalidad) destacando la sepsis obstétrica con mayor fallecimiento y mayor tiempo de internación. CONCLUSIÓN: los cambios fisiológicos propios del embarazo, la convierten en una paciente de riesgo, identificando la diferencia de iones fuertes aparente y abreviada como posibles factores pronóstico en la paciente obstétrica en estado crítico. PALABRAS CLAVE: estado acido-base, obstetricia crítica, gran altitud

OBJECTIVE: to describe the acid base status in critically ill obstetric patients at very high altitude, at the time of admission to the Intensive Care Unit. METHODOLOGY: retrospective descriptive study. All obstetric patients admitted to the Adult Intensive Care Unit of the Hospital del Norte in the city of El Alto, La Paz at 4150 meters above sea level, in the period January 2019-January 2022, are included. RESULTS: 79 patients were admitted, with a mean age of 29 years (standard deviation 8.06 years), 52 cases (66%) due to severe preeclampsia, 14 cases (18%) due to obstetric hemorrhage, 8 cases (10%) due to obstetric sepsis. and 5 (6%) due to various diagnoses such as supraventricular tachycardia and poisoning, there were 8 deceased patients (10% mortality), highlighting obstetric sepsis with the highest death rate and longest hospital stay. DISCUSSION: the physiological changes during pregnancy make her a risk patient, identifying the apparent and abbreviated strong ion difference as possible prognostic factors in the critically ill obstetric patient

Impact of High-Flow Nasal Cannula Use in Subjects With COVID-19 ARDS at High Altitudes: Clinical Presentation and Prognostic Factors.

BACKGROUND: High-flow nasal cannula (HFNC) reduces the need for intubation in adult subject with acute respiratory failure. Changes in hypobaric hypoxemia have not been studied for subject with an HFNC in ICUs at altitudes > 2,600 m above sea level. In this study, we investigated the efficacy of HFNC treatment in subjects with COVID-19 at high altitudes. We hypothesized that progressive hypoxemia and the increase in breathing frequency associated with COVID-19 in high altitudes affect the success of HFNC therapy and may also influence the performance of the traditionally used predictors of success and failure. METHODS: This was a prospective cohort study of subjects >18 y with a confirmed diagnosis of COVID-19-induced ARDS requiring HFNC who were admitted to the ICU. Subjects were followed up during the 28 d of HFNC treatment or until failure. RESULTS: One hundred and eight subjects were enrolled. At admission to the ICU, FIO2 delivery between 0.5-0.8 (odds ratio 0.38 [95% CI 0.17-0.84]) was associated with a better response to HFNC therapy than oxygen delivery on admission between 0.8-1.0 (odds ratio 3.58 [95% CI 1.56-8.22]). This relationship continued during follow-ups at 2, 6, 12, and 24 h, with a progressive increase in the risk of failure (odds ratio 24 h 13.99 [95% CI 4.32-45.26]). A new cutoff for the ratio of oxygen saturation (ROX) index (ROX ≥ 4.88) after 24 h of HFNC administration was demonstrated to be the best predictor of success (odds ratio 11.0 [95% CI 3.3-47.0]). CONCLUSIONS: High-altitude subjects treated with HFNC for COVID-19 showed a high risk of respiratory failure and progressive hypoxemia when FIO2 requirements were > 0.8 after 24 h of treatment. In these subjects, personalized management should include continuous monitoring of individual clinical conditions (such as oxygenation indices, with cutoffs adapted to those corresponding to high-altitude cities).

Indice respiratorio en Medicina Critica a muy Alta Altitud / Respiratory Index in Very High Altitude Critical Medicine

Actualmente se reconoce que el índice respiratorio, correspondiente al cociente de la diferencia de presión de dióxido de carbono venosa arterial (DPv-aCO2) sobre la diferencia del contenido de oxígeno arteriovenoso ((DPv-aCO2/DCa-vO2) orienta sobre el gasto cardiaco (flujo sanguíneo micro circulatorio o perfusión) y el metabolismo anaeróbico, respectivamente, que puede ser el objetivo final de la monitorización gasométrica en el paciente en estado crítico.

Ictus en cuidado intensivo a muy alta altitud / Stroke in intensive care at very high altitude

Objetivo: Describir la casuística de los pacientes con ictus atendidos en la Unidad de Cuidados Intensivos del Centro de Trauma "Hospital Corazón de Jesús" a 4150 metros sobre el nivel del mar. Metodología (casuística): Estudio retrospectivo transversal descriptivo. Se incluyen todos los pacientes residentes permanentes a muy alta altitud, ingresados en el periodo Enero 2019-Enero 2022. Para el análisis de los datos se utilizó estadística descriptiva y creación de una base de datos en el programa Excel v16. Resultados: Se ingresaron 74 pacientes, 39 mujeres (53%), edad promedio de 64.82 (± 10.53 años), 51 casos (69%) por ictus isquémico y 23 casos (31%) por ictus hemorrágico, con una mortalidad de 18% para ictus isquémico y 17% para ictus hemorrágico. La escala de coma de Glasgow, el nivel del hemoglobina, la presión parcial arterial de dióxido de carbono, hiperoxemia y depuración de lactato al ingreso se constituyen en factores pronósticos de mortalidad. Así también se evidencia que, la hipertensión arterial sistémica así como la eritrocitosis son comorbilidades asociadas a la presentación de ictus a muy alta altitud. Discusión: La mortalidad en el presente estudio fue similar a la literatura consultada, constatando que la altitud, por sí sola, no produce mortalidad ni ofrece algún tipo de protección, al menos en pacientes neurocríticos con ictus a muy alta altitud. De igual manera se verifica la edad de presentación del ictus en concordancia a la literatura internacional. Conclusiones: Resulta imperativo describir la casuística concerniente a nuestros Centros Asistenciales para conocer las características propias de la patología de altitud destacando la presión parcial de dióxido de carbono, la hiperoxemia y la depuración de lactato como factores pronóstico en nuestro medio.

Objective: To describe the casuistry of stroke patients treated in the Intensive Care Unit of the Trauma Center "Hospital Corazón de Jesús". Methodology (casuistry): Retrospective cross-sectional descriptive study. All permanent resident patients at very high altitude, admitted in the period January 2019-January 2022, were included. For the analysis of the data, descriptive statistics and creation of a database in the Excel v16 program were used. Results: 74 patients were admitted, 39 women (53%), mean age 64.82 (± 10.53 years), 51 cases (69%) due to ischemic stroke and 23 cases (31%) due to hemorrhagic stroke, with a mortality of 18%. The Glasgow coma scale, hemoglobin level, arterial partial pressure of carbon dioxide, hyperoxemia, and lactate clearance on admission are prognostic factors for mortality. Thus, it is also evident that systemic arterial hypertension as well as erythrocytosis are comorbidities associated with the presentation of stroke at very high altitude. Discussion: Mortality in this study was similar to the literature consulted, confirming that altitude alone does not cause mortality or offer any type of protection, at least in neurocritical patients with stroke at very high altitude. In the same way, the age of presentation of the stroke is concordant with the international literature. Conclusion: It is imperative to describe the casuistry concerning our Health Centers to know the characteristics of the altitude pathology.

The ultrasound-based cardiac output monitoring is a useful tool to define baseline hemodynamic parameters in healthy permanent residents at high altitude: results of a monocentric pilot study.

Previous studies on the cardiac data of healthy permanent residents living in high-altitude regions such as Tibet and the Andes have yielded inconsistent findings and significant disparities. These discrepancies can be mainly attributed to the invasive methods conventionally used for parameter evaluation. However, with the introduction of cutting-edge ultrasound technology, there is now an innovative approach to addressing and reconciling these variations. In this pilot study, we employed an ultrasound-based cardiac output monitoring (USCOM) device to evaluate cardiac output and related hemodynamic variables in a group of 20 healthy high-altitude Andean residents (comprising 10 men and 10 women) aged between 26 and 35 years old. The monocentric study was carried out in La Paz, Bolivia, located between at an altitude of 3,600-4,000 m. A total of 60 hemodynamic measurements were evaluated, accounting for three technical replicates per subject. Our results showed strong intrasubject reproducibility and revealed important differences related to both sex and hemodynamic parameters in highlanders compared to individuals residing at sea level. We conclude that USCOM represents a highly reliable technology for performing hemodynamic measurements in high-altitude residents. Our preliminary findings underscore the need for larger studies, encompassing larger sample sizes, specifically tailored to gender considerations, and extendable to broader highland populations. These findings have special significant implications for the management of hemodynamics in intensive care and postoperative settings, warranting further comprehensive research efforts.

Oxygen therapy limiting peripheral oxygen saturation to 89-93% is associated with a better survival prognosis for critically ill COVID-19 patients at high altitudes.

Patients admitted to the Intensive Care Unit (ICU) with acute hypoxemic respiratory failure automatically receive oxygen therapy to improve inspiratory oxygen fraction (FiO2). Supplemental oxygen is the most prescribed drug for critically ill patients regardless of altitude of residence. In high altitude dwellers (i.e. in La Paz [≈3,400 m] and El Alto [≈4,150 m] in Bolivia), a peripheral oxygen saturation (SatpO2) of 89-95% and an arterial partial pressure of oxygen (PaO2) of 50-67 mmHg (lower as altitude rises), are considered normal values ​​for arterial blood. Consequently, it has been suggested that limiting oxygen therapy to maintain SatpO2 around normoxia may help avoid episodes of hypoxemia, hyperoxemia, intermittent hypoxemia, and ultimately, mortality. In this study, we evaluated the impact of oxygen therapy on the mortality of critically ill COVID-19 patients who permanently live at high altitudes. A multicenter cross-sectional descriptive observational study was performed on 100 patients admitted to the ICU at the "Clinica Los Andes" (in La Paz city) and "Agramont" and "Del Norte" Hospitals (in El Alto city). Our results show that: 1) as expected, fatal cases were detected only in patients who required intubation and connection to invasive mechanical ventilation as a last resort to overcome their life-threatening desaturation; 2) among intubated patients, prolonged periods in normoxia are associated with survival, prolonged periods in hypoxemia are associated with death, and time spent in hyperoxemia shows no association with survival or mortality; 3) the oxygenation limits required to effectively support the intubated patients' survival in the ICU are between 89% and 93%; 4) among intubated patients with similar periods of normoxemic oxygenation, those with better SOFA scores survive; and 5) a lower frequency of observable reoxygenation events is not associated with survival. In conclusion, our findings indicate that high-altitude patients entering an ICU at altitudes of 3,400 - 4,150 m should undergo oxygen therapy to maintain oxygenation levels between 89 and 93 %.

Cuidado intensivo COVID 19 a muy alta altitud / Critical care in COVID 19 at very high altitude

Objetivo: Describir la casuística de los pacientes críticamente enfermos COVID-19 atendidos en la Unidad de Cuidados Intensivos del Hospital del Norte, primer Hospital del Tercer Nivel de Complejidad de la ciudad de El Alto y Centro de Referencia Departamental. Metodología: Estudio retrospectivo transversal observacional. Se incluyen todos los pacientes residentes permanentes a muy alta altitud, ingresados en el periodo 25 Marzo 2020-25 Noviembre 2021. Para el análisis de los datos se utilizó estadística descriptiva y creación de una base de datos en el programa Excel v18. Resultados: Se ingresaron 373 pacientes, 212 (57%) varones, así como 161 (43%) mujeres. Se tiene una mortalidad corregida del 48%, la estancia promedio en la UCI es de 18 días, 26 (± 4) en el grupo de supervivientes y 11 (± 2) en el grupo de fallecidos. La edad promedio de supervivientes es de 47.25 años (± 12 años) y la edad promedio de fallecidos 56.58 años (± 14 años) con valor de p por t de Student de 0.004. La comorbilidad más frecuentemente encontrada fue la hipertensión arterial sistémica en 157 (42%) casos. Únicamente 2 casos contaban con vacuna antiCOVID-19. Discusión: La mortalidad corregida es similar a la casuística reportada en la literatura internacional en Unidades de Cuidados Intensivos. El presente estudio apoya el hecho que la altitud no afecta la evolución de los pacientes críticos COVID-19. Conclusión: Resulta imperativo describir la casuística concerniente a nuestros Centros Asistenciales.

Depuración del lactato y mortalidad en residentes de la gran altitud con trauma grave / Lactate clearance and mortality in high altitude residents with severe trauma

Introducción: Diversos estudios reportan que la depuración del lactato está asociado a la mortalidad en los pacientes críticos. Se describe la relación entre la depuración del lactato y la normalización del lactato con la mortalidad en los pacientes residentes de la gran altitud con trauma grave. Por lo cual es importante conocer la mortalidad de los pacientes con trauma grave en la altitud y la distribución lesional del trauma grave en la altitud. Material y Métodos: Estudio de cohorte, retrospectivo, realizado en una unidad de cuidados intensivos a 4,150 "msnm" en pacientes que ingresaron por trauma grave. Los criterios de inclusión fueron: a) Diagnóstico de trauma grave. b) Injury severity score mayor a 16. c) Presencia del resultado del análisis del lactato al ingreso y a las 6 horas en UCI y d) Residente de la altitud desde los 12 años. Se excluyeron los pacientes con historias clínicas incompletas y no legibles. Resultados: Se incluyeron 160 pacientes, Mortalidad del 15%, 65% de las lesiones fueron por trauma encefálico grave. En el grupo de supervivientes (n=136), la depuración de lactato fue del 52,27% y en el grupo de fallecidos fue 21,38%. En relación a la normalización (lactato< 2 mmol/L), el grupo de supervivientes tuvo 47% frente a 1% de los fallecidos. Conclusiones: La depuración de lactato y la normalización del lactato a las 6 seis horas son factores de protección para disminuir la mortalidad por trauma grave. La mortalidad por trauma grave es 15%. El trauma encefálico grave fue la lesión más frecuente.

Background: Several studies report that lactate clearance is associated with mortality in critically ill patients. Objectives: To describe the relationship between lactate clearance and lactate normalization with mortality in high-altitude resident patients with severe trauma. To know the mortality of patients with severe trauma at altitude. Know the injury distribution of severe trauma at altitude. Material and Methods: Epidemiological, observational, analytical, cohort, retrospective study, carried out in an intensive care unit located at 4,150 "masl" in patients admitted for severe trauma. The inclusion criteria were: a) Diagnosis of severe trauma. b) Injury severity score greater than 16. c) Presence of the result of the lactate analysis at admission and at 6 hours in the ICU and d) Resident of the altitude since the age of 12. Patients with incomplete and unreadable medical records were excluded. Results: 160 patients were included, mortality of 15%, 65% of the injuries were due to severe brain trauma. In the group of survivors (136), lactate clearance was 52.27% and in the group of deceased it was 21.38%. In relation to normalization (lactate <2 mmol / L), the group of survivors had 47% compared to 1% of the deceased. Conclusions: Lactate clearance and lactate normalization at 6 hours are protective factors to decrease mortality from severe trauma. Mortality from severe trauma is 15%. Severe head trauma was the most frequent injury.

Low serum erythropoietin levels are associated with fatal COVID-19 cases at 4,150 meters above sea level.

Previous studies suggested that erythropoietin (EPO) may protect against severe COVID-19-induced injuries, ultimately preventing mortality. This hypothesis is based on the fact that, in addition to promoting the increase in red blood cells, EPO is an anti-inflammatory, anti-apoptotic and protective factor in several non-erythropoietic tissues. Furthermore, EPO promotes nitric oxide production in the hypoxic lung and stimulates ventilation by interacting with the respiratory centers of the brainstem. Given that EPO in the blood is increased at high-altitude, we evaluated the serum levels of EPO in critical patients with COVID-19 at "Hospital Agramont" in the city of El Alto (4150 masl) in Bolivia. A total of 16 patients, 15 men, one woman, with a mean age of 55.8 ± 8.49 years, admitted to the Intensive Care Unit were studied. All patients were permanent residents of El Alto, with no travel history below 3000 masl for at least one year. Blood samples were collected upon admission to the ICU. Serum EPO concentration was assessed using an ELISA kit, and a standard technique determined hemoglobin concentration. Only half of the observed patients survived the disease. Remarkably, fatal cases showed 2.5 times lower serum EPO than survivors (2.78 ± 0.8643 mU/mL vs 7.06 ± 2.713 mU/mL; p = 0.0096), and 1.24 times lower hemoglobin levels (13.96 ± 2.56 g/dL vs 17.41 ± 1.61 g/dL; p = 0.0159). While the number of cases evaluated in this work is low, our findings strongly warrant further investigation of EPO levels in COVID-19 patients at high and low altitudes. Our results also support the hypothesis that exogenous EPO administration could help critically ill COVID-19 patients overcome the disease.

Gasometría arterial en embarazo a muy alta altitud / Arterial blood gas analysis during pregnancy at a very high altitude

La gasometría arterial es fundamental en el diagnóstico y manejo del medio interno. El objetivo es caracterizar los valores de gasometría arterial en gestantes sanas con embarazo normoevolutivo residentes a 4 150 metros sobre el nivel del mar. Serie de casos llevada a cabo durante la gestión 2019, la cual incluye pacientes sin clínica ni antecedentes de enfermedades cardiopulmonares o hematológicas, así como ausencia de tabaquismo y residencia de al menos los últimos 6 meses. Se incluye 30 pacientes, media de edad 25.23 años (desvío estándar 3.69), con edad gestacional media de 26 semanas (desvío estándar 5.5). El valor de pH tiende a ser más alto, así como los valores de PaO2, PaCO2, HCO3 y SatpO2% son más bajos, incluso en comparación con adultos sanos residentes de la misma altitud. Existe cierta tendencia positiva hacia el incremento progresivo del pH mientras la edad gestacional avanza. La gasometría arterial en la altura, debe ser interpretada con suma precaución en relación a las condiciones barométricas, proporcionándose así, valiosa información con aplicación a la obstetricia crítica a muy alta altitud.

Arterial blood gases analysis is essential in the diagnosis and management of pathologies. The objective is to characterize arterial blood gases values in healthy pregnant residents at 4150 meters above sea level. Series case performed during 2019, including patients without a clinical features or antecedents of cardiopulmonary or hematological diseases as well as absence of smoking and residence for at least the last 6 months. Thirty patients are included, mean age 25.23 years (standard deviation 3.69), with average gestational age of 26 weeks (standard deviation 5.5). The pH tends to be higher, as well as the values of PaO2, PaCO2, HCO3 and SatpO2% are lower, even compared to healthy adults living at the same altitude. There is some positive trend towards progressive pH is higher such as gestational age progresses. Arterial gas blood analysis at altitude, should be interpreted with extreme caution in relation to barometric conditions, thus providing, valuable information to critical care obstetrics at very high altitude

Caracterización de la preeclampsia a gran altitud / Characterization of high-altitude preeclampsia

Introducción: La muy alta altitud, es un reto para la adaptación humana debido a la disminución de la presión barométrica y consecuente disminución en la presión parcial arterial de oxígeno. A su vez se encuentra descrito un incremento de endotelina, tromboxano A2 y Factor de necrosis tumoral alfa con reducción asociada de prostaciclina en casos de preeclampsia. El objetivo del presente estudio es describir las características clínicas de pacientes con preeclampsia a 4150 metros sobre el nivel del mar.

Hemorragia intracerebral espontánea durante el embarazo: reporte de caso / Spontaneous intracerebral hemorrhage during pregnancy: case report

Introducción: La hemorragia intracerebral espontánea (HICE) o no traumática es una causa importante de morbilidad y mortalidad en todo el mundo, la cual ha tenido un incremento dramático durante la última década en casos reportados durante el embarazo. El objetivo es presentar en caso de una paciente con hemorragia intracerebral espontanea quien recibió neurocirugía y manejo en cuidados intensivos con evolución favorable de binomio materno fetal.