Evolución de los pacientes con insuficiencia cardiaca aguda secundaria a infarto agudo de miocardio tratados con ventilación mecánica no invasiva / Outcome of patients with acute heart failure secondary to acute myocardial infarction treated with noninvasive mechanical ventilation

Introducción y objetivos: La ventilación no invasiva (VNI) es capaz de reducir la necesidad de intubación endotraqueal y la mortalidad de los pacientes con insuficiencia cardiaca aguda (ICA). Sin embargo, de muchos de los ensayos clínicos se ha excluido a los pacientes con ICA secundaria a síndrome coronario agudo o infarto agudo de miocardio (SCA-IAM). El objetivo de este estudio es comparar la efectividad de la VNI entre pacientes con ICA desencadenada por SCA-IAM y por otras causas. Métodos: Estudio prospectivo de cohortes, durante un periodo de 20 años, de todos los pacientes con ICA tratados con VNI ingresados en una unidad de cuidados intensivos. Se agrupó a los pacientes por la presencia o ausencia de SCA-IAM como causante del evento de ICA. Se definió el fracaso de la VNI por la necesidad de intubación endotraqueal o muerte. Resultados: Se analizó a 1.009 pacientes, 403 (40%) con SCA-IAM y 606 (60%) con otras etiologías. La VNI fracasó en 61 casos (15,1%) del grupo de SCA-IAM y 64 (10,6%) del grupo sin SCA-IAM (p=0,031), sin diferencias en la mortalidad hospitalaria (el 16,6 y el 14,9%; p=0,478). Conclusiones: El SCA-IAM como causa desencadenante de la ICA no influye en el pronóstico de los pacientes con insuficiencia respiratoria aguda que precisan asistencia respiratoria no invasiva (AU)

Introduction and objectives: Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. Methods: Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. Results: A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P=.031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P=.478). Conclusions: The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support (AU)

Diagnóstico de la embolia pulmonar. El punto de vista del médico clínico / Diagnosing pulmonary embolisms: the clinician's point of view

La tromboembolia pulmonar (TEP) es una enfermedad frecuente y potencialmente grave. Es necesario el conocimiento de los conceptos básicos que rigen la utilidad de las pruebas para poder realizar una aproximación correcta a su proceso diagnóstico. La TEP se caracteriza porque su diagnóstico es un ejemplo de la aplicación de las probabilidades condicionadas de Bayes a la clínica diaria. Para una correcta interpretación de las pruebas diagnósticas disponibles, es necesario analizar diferentes conceptos que son fundamentales para la toma de decisiones. Es preciso conocer el significado de los cocientes de probabilidad, los intervalos de confianza del 95% y los umbrales de decisión. Así, la utilidad de la determinación del dímero D, o la realización de una angiografía pulmonar mediante tomografía computarizada u otras pruebas de imagen, se debe a la capacidad de modificar la probabilidad pretest de padecer la enfermedad a una probabilidad posterior que se encuentre por encima o por debajo de los umbrales de acción. El objetivo de esta revisión es clarificar la secuencia diagnóstica de la enfermedad tromboembólica pulmonar, analizando las principales herramientas diagnósticas, clínicas, analíticas y de imagen, poniendo especial énfasis en los principios que rigen la medicina basada en la evidencia (AU)

Pulmonary thromboembolism is common and potentially severe. To ensure the correct approach to the diagnostic workup of pulmonary thromboembolism, it is essential to know the basic concepts governing the use of the different tests available. The diagnostic approach to pulmonary thromboembolism is an example of the application of the conditional probabilities of Bayes’ theorem in daily practice. To interpret the available diagnostic tests correctly, it is necessary to analyze different concepts that are fundamental for decision making. Thus, it is necessary to know what the likelihood ratios, 95% confidence intervals, and decision thresholds mean. Whether to determine the D-dimer concentration or to do CT angiography or other imaging tests depends on their capacity to modify the pretest probability of having the disease to a posttest probability that is higher or lower than the thresholds for action. This review aims to clarify the diagnostic sequence of thromboembolic pulmonary disease, analyzing the main diagnostic tools (clinical examination, laboratory tests, and imaging tests), placing special emphasis on the principles that govern evidence-based medicine (AU)

Diagnosing pulmonary embolisms: the clinician's point of view. / Diagnóstico de la embolia pulmonar. El punto de vista del médico clínico.

Pulmonary thromboembolism is common and potentially severe. To ensure the correct approach to the diagnostic workup of pulmonary thromboembolism, it is essential to know the basic concepts governing the use of the different tests available. The diagnostic approach to pulmonary thromboembolism is an example of the application of the conditional probabilities of Bayes' theorem in daily practice. To interpret the available diagnostic tests correctly, it is necessary to analyze different concepts that are fundamental for decision making. Thus, it is necessary to know what the likelihood ratios, 95% confidence intervals, and decision thresholds mean. Whether to determine the D-dimer concentration or to do CT angiography or other imaging tests depends on their capacity to modify the pretest probability of having the disease to a posttest probability that is higher or lower than the thresholds for action. This review aims to clarify the diagnostic sequence of thromboembolic pulmonary disease, analyzing the main diagnostic tools (clinical examination, laboratory tests, and imaging tests), placing special emphasis on the principles that govern evidence-based medicine.

Evaluación del impacto de un plan de cuidados de enfermería de pacientes con EPOC con diagnóstico enfermero «Manejo inefectivo del régimen terapéutico», en términos de mejora del criterio de resultado de enfermería (NOC) «Conocimiento del régimen terapeutico» / Impact assessment of a plan of nursing care of patients diagnosed with COPD nurse «Ineffective management of therapeutic regimen», in terms of improving the nursing outcomes (NOC) «Knowledge of therapeutic regime»

Objetivo: Conocer el impacto en el ‘Conocimiento del régimen terapéutico’, en pacientes con un plan de cuidados sobre ‘Manejo inefectivo del régimen terapéutico’. Método: Estudio cuasiexperimental, en dos Hospitales Generales Universitarios (junio 2007 - diciembre 2008) pacientes con EPOC. Grupo intervención: plan de cuidados desarrollado mediante taxonomías; grupo control: asistencia hospitalaria habitual. Resultados: 143 pacientes incluidos en el estudio (grupo intervención=56; grupo control =87). Mejora NOC a las 2 semanas (69.2% intervención vs. 10,7% control; p<,008); mejora NOC a las 24 semanas (68.7% vs.10.1%, p<,001). Indicadores descripción justificación régimen terapéutico; actividad prescrita; beneficios del tratamiento mejoran con p<,001. Conclusiones: La implementación de un plan de cuidados dirigido al alta orientado al incremento del Implicaciones para la práctica: La implementación de taxonomías en planificación de cuidados orientados al alta constituyen una herramienta para evaluar resultados de las intervenciones enfermeras y su evolución (AU)

Purpose: To determine the impact on the «Knowledge of the therapeutic regimen», in patients with a care plan on "ineffective management of therapeutic regimen." Methods: Quasi-experimental study in two General Hospitals University (June 2007 - December 2008) COPD patients. Group intervention: care plan developed by taxonomies; Control group: usual hospital care. Findings: 143 patients were Recruited (Intervention group = 56, control group = 87). NOC improvement at 2 weeks (69.2% vs 10.7% intervention control; p <.008); NOC improvement at 24 weeks (68.7% vs.10.1%; p <.001). Indicators "description regimen justification"; "Prescribed activity"; "Treatment benefit" better with p <.001. Conclusions: The implementation of a discharged plan care direct to increase the nursing outcome classification improves management of therapeutic regimen. Implications for nursing practice: The implementation of taxonomies in care planning discharged are a tool that allow to evaluate outcomes of nursing interventions and its evolution (AU)

[Quality of initial prescription of home oxygen therapy in a healthcare area of the Murcia Region (Spain)]. / Calidad de la prescripción inicial de la oxigenoterapia domiciliaria en un área sanitaria de la Región de Murcia.

OBJECTIVE: To analyse the quality of the prescription of home oxygen therapy (OT) in a health area of Murcia. METHODS: A prospective study of 125 patients in a respiratory therapy clinic, evaluated with a questionnaire and blood-gas analysis while breathing ambient air. Related respiratory therapy was also assessedin COPD and asthma patients. RESULTS: We studied 125 cases in the 3 months following the prescription of home oxygen therapy in 72 men (58%) and 53 women (42%) with a mean age of 77.2 ± 11.6. The most common type of home OT prescribed was for palliative cases in 45 patients (36%), followed by COPD in 42 (33.6%). In 88 (92%) of the 96 medical reports that we evaluated, insufficient data as to how to administer oxygen were available. Twenty-five percent of home OT prescriptions were given without blood-gas analyses, and in the 65 cases with a blood-gas analysis only 11 (17%) met oxygen value criteria for home OT as per regulations. Oxygen desaturation was not present in 31% of the palliative care home OT cases. The analysis of blood-gases during the clinic visit in non-palliative care cases demonstrated that 61% did not meet the blood-gas criteria to continue on home OT. Eighty percent of COPD and asthma patients on home OT did not receive the correct respiratory therapy. CONCLUSIONS: Quality problems in the prescription of home OT exist in our area. Palliative care is the principal reason for home OT prescriptions. In COPD and asthma patients who receive home OT, related respiratory therapy is not ideal.

Calidad de la prescripción inicial de la oxigenoterapia domiciliaria en un área sanitaria de la Región de Murcia / Quality of initial prescription of home oxygen therapy in a healthcare area of the Murcia Region (Spain)

Objetivo. Analizar la calidad de la prescripción de oxigenoterapia domiciliaria (OD) en un área sanitaria de Murcia. Métodos. Estudio prospectivo de 125 pacientes en consulta de terapias respiratorias, a los que se evaluó con un cuestionario y gasometría arterial respirando aire del ambiente. En EPOC y asma se valoró también el tratamiento inhalador asociado. Resultados. Estudiamos 125 casos en los 3 meses siguientes a la indicación de OD, 72 varones (58%) y 53 mujeres (42%), con una media de edad de 77,2±11,6 años. La indicación de OD más frecuente se consideró paliativa en 45 (36%), seguida de la EPOC, en 42 (33,6%). En 88 de los 96 informes médicos que se evaluaron (92%), no había datos suficientes de cómo administrar el oxígeno. Un 25% de las indicaciones de OD se realizaron sin gasometría arterial y, de 65 donde había gasometría, sólo en 11 (17%) los valores de oxígeno reunían criterios de OD según las normativas. En el 31% de las indicaciones paliativas de OD, no estaba la desaturación de oxígeno. El análisis de los gases arteriales en el momento de la consulta en los casos sin indicación paliativa, constató que el 61% no tenía criterios gasométricos de continuación de OD. El 80% de los pacientes con EPOC y asma con OD no recibía tratamiento inhalador correcto. Conclusiones. Se detectaron problemas de calidad en la prescripción de la OD en nuestra área. El tratamiento paliativo fue la principal causa de indicación de OD. En pacientes con EPOC y asma que recibían oxígeno domiciliario, el tratamiento inhalador asociado no resultó óptimo(AU)

Objective. To analyse the quality of the prescription of home oxygen therapy (OT) in a health area of Murcia. Methods. A prospective study of 125 patients in a respiratory therapy clinic, evaluated with a questionnaire and blood-gas analysis while breathing ambient air. Related respiratory therapy was also assessedin COPD and asthma patients. Results. We studied 125 cases in the 3 months following the prescription of home oxygen therapy in 72 men (58%) and 53 women (42%) with a mean age of 77.2±11.6. The most common type of home OT prescribed was for palliative cases in 45 patients (36%), followed by COPD in 42 (33.6%). In 88 (92%) of the 96 medical reports that we evaluated, insufficient data as to how to administer oxygen were available. Twenty-five percent of home OT prescriptions were given without blood-gas analyses, and in the 65 cases with a blood-gas analysis only 11 (17%) met oxygen value criteria for home OT as per regulations. Oxygen desaturation was not present in 31% of the palliative care home OT cases. The analysis of blood-gases during the clinic visit in non-palliative care cases demonstrated that 61% did not meet the blood-gas criteria to continue on home OT. Eighty percent of COPD and asthma patients on home OT did not receive the correct respiratory therapy. Conclusions. Quality problems in the prescription of home OT exist in our area. Palliative care is the principal reason for home OT prescriptions. In COPD and asthma patients who receive home OT, related respiratory therapy is not ideal(AU)

Estudio descriptivo sobre resultados de salud de pacientes oncohematológicos e intervenciones enfermeras / Descriptive study of nursing-sensitive outcomes in oncohematological patients and nursing interventions

Objetivo. Conocer el estado de los principales resultados de salud de los pacientes oncohematológicos durante su ingreso y evaluar algunas de sus intervenciones enfermeras. Material y métodos. Estudio prospectivo observacional realizado en las unidades de oncohematología del Hospital Morales Meseguer, con pacientes que precisaron ingreso entre marzo de 2006 y junio de 2007. Resultados. Se estudiaron a 56 pacientes. El 69,6% (39 pacientes) presentaba algún nivel de mucositis, apareciendo valoraciones enfermeras objetivas en el 10,7% (6). El 92,9% (52) de los pacientes estaba bajo tratamiento antiemético, pero en el 48,2% (27) no se recoge ningún tipo de registro de valoración enfermera del síntoma. Se realizó interconsulta a la Unidad de Nutrición para 10 pacientes (17,9%). Los niveles de ansiedad y el impacto psicosocial descienden a lo largo de la estancia hospitalaria, sin embargo, aumenta la satisfacción y los familiares presentan mayor sobrecarga. Apareció una úlcera por presión (UPP). Hubo un 8,2% (4) de colonizaciones de catéter y se produjeron 5 bacteriemias relacionadas con catéter (BRC); las obstrucciones de éstos se produjeron en el 39,3% (22). Conclusiones. La incidencia de aparición de mucositis, UPP y BRC es menor que en otros estudios. El proceso de valoración del dolor y de las náuseas y vómitos no está normalizado. La ansiedad muestra unos niveles inferiores a otros estudios. Su mejoría, al igual que en el ajuste psicosocial, apunta a un proceso de adaptación a la enfermedad. El aumento de la sobrecarga del cuidador se relaciona con el largo proceso. Su satisfacción frente a los cuidados enfermeros ha alcanzado 55 puntos de la escala, cuyo nivel máximo es de 70(AU)

Objective.To assess the main nursing-sensitive outcomes in oncohematological patients admitted to hospital and to evaluate nursing interventions. Material and methods. We performed a prospective, observational study in the oncohematological units of the Morales Meseguer Hospital. The sample included patients admitted from March 2006 to June 2007. Results. A total of 56 patients were studied. Of these, 39 patients (69.6%) had some degree of mucositis but only six patients (10.7%) were assessed objectively by nurses. Fifty-two patients (92.9%) received anti-emetic treatment, but there were no reports of nausea or vomiting in 27 (48.2%). Ten patients (17.9%) were referred to the nutritional unit. Anxiety levels and psychosocial impact decreased during hospital admission and patient satisfaction increased but family members experienced greater stress. Pressure ulcer developed in only one patient. Four catheters (8.2%) became infected and there were five cases of catheter-related bacteremia. There were 22 cases of catheter obstruction (39.9%). Conclusions. The incidence of mucositis, pressure ulcer and catheter-related bacteremia was lower than in other studies. There was no standard assessment of pain, nausea or vomiting. Anxiety levels were lower than in other studies. Improvement and psychosocial adjustment suggested a process of adaptation to the disease. The increase in caregiver burden was related to the disease in the long term. Satisfaction with nursing care was 55 points on a 70-point scale(AU)

[Descriptive study of nursing-sensitive outcomes in oncohematological patients and nursing interventions]. / Estudio descriptivo sobre resultados de salud de pacientes oncohematológicos e intervenciones enfermeras.

OBJECTIVE: To assess the main nursing-sensitive outcomes in oncohematological patients admitted to hospital and to evaluate nursing interventions. MATERIAL AND METHODS: We performed a prospective, observational study in the oncohematological units of the Morales Meseguer Hospital. The sample included patients admitted from March 2006 to June 2007. RESULTS: A total of 56 patients were studied. Of these, 39 patients (69.6%) had some degree of mucositis but only six patients (10.7%) were assessed objectively by nurses. Fifty-two patients (92.9%) received anti-emetic treatment, but there were no reports of nausea or vomiting in 27 (48.2%). Ten patients (17.9%) were referred to the nutritional unit. Anxiety levels and psychosocial impact decreased during hospital admission and patient satisfaction increased but family members experienced greater stress. Pressure ulcer developed in only one patient. Four catheters (8.2%) became infected and there were five cases of catheter-related bacteremia. There were 22 cases of catheter obstruction (39.9%). CONCLUSIONS: The incidence of mucositis, pressure ulcer and catheter-related bacteremia was lower than in other studies. There was no standard assessment of pain, nausea or vomiting. Anxiety levels were lower than in other studies. Improvement and psychosocial adjustment suggested a process of adaptation to the disease. The increase in caregiver burden was related to the disease in the long term. Satisfaction with nursing care was 55 points on a 70-point scale.

Utilización de la ventilación no invasiva en la insuficiencia respiratoria aguda. Estudio multicéntrico en unidades de cuidados intensivos / Use of non-invasive ventilation in acute respiratory failure. Multicenter study in intensive care units

Objetivo. Estudiar el uso de la ventilación no invasiva (VNI) en la insuficiencia respiratoria aguda, en las unidades de cuidados intensivos (UCI) de España. Métodos. Se realizó una encuesta a 254 UCI. Al final de ésta se invitó a participar en un estudio multicéntrico retrospectivo, y proporcionar información detallada sobre pacientes ventilados. Resultados. Contestaron 123 UCI; 119 utilizaban la VNI, de manera muy variable. En la enfermedad pulmonar obstructiva crónica (EPOC), la VNI fue de primera elección en el 89% de las unidades; en el edema agudo de pulmón (EAP), el 79%; en la insuficiencia respiratoria tras la extubación, el 53%; en la neumonía, el 53%, y en el síndrome de distrés respiratorio agudo (SDRA), el 17%. Su utilización en la EPOC fue ocasional o nula en el 11% de las unidades, y en el EAP, en el 21%. 18 hospitales enviaron información de 432 pacientes ventilados, de los que 232 (54%) recibieron VNI como primera elección. La neumonía o el SDRA fueron factores independientes en relación con el fracaso de la VNI (odds ratio ajustada [ORa] = 5,71; intervalo de confianza [IC] del 95%, 1,83-17,8; p = 0,003). La admisión en una unidad que ventilara de forma no invasiva a más de 50 pacientes/año (ORa = 0,22; IC del 95%, 0,07-0,63; p = 0,005) y una mayor razón PaO2/FIO2 tras una hora de ventilación (ORa = 0,98 por punto; IC del 95%, 0,97-0,99; p < 0,001) fueron factores protectores. Conclusiones. La VNI es ampliamente utilizada en las UCI de España, pero es posible que siga estando infrautilizada en la EPOC y el EAP. El diagnóstico de neumonía o SDRA fue un factor independiente en relación con el fracaso. Ventilar a más de 50 pacientes/año y una mayor PaO2/FIO2 tras una hora fueron factores protectores(AU)

Objectives. Study the use of non-invasive ventilation (NIV) in patients with acute respiratory failure in intensive care units (ICUs) in Spain. Methods. A questionnaire was sent to 254 ICUs, after which, they were invited to participate in a multicenter, retrospective study, providing detailed information on ventilated patients. Results. Answers were received from 123 hospitals. Of these, 119 used NIV, although its use varied greatly. NIV is the treatment of choice in 89% of the units for chronic obstructive pulmonary disease (COPD), in 79% for acute pulmonary edema (APE), in 53% for postextubation failure, in 53% for pneumonia 53%, and in 17% for acute respiratory distress syndrome (ARDS). It was used occasionally in COPD in 11% of the units, and in 21% of the units for APE. Eighteen hospitals provided additional information on 432 ventilated patients, 232 (54%) of whom received NIV as first line therapy. Presence of pneumonia or acute respiratory distress syndrome (ARDS) was an independent predictive factor of NIV failure (ORa = 5.71; CI 95%, 1.83-17.8; p = 0.003). Admission in a unit with experience in NIV in > 50 patients/year (ORa = 0.22; CI 95%, 0.07-0.63; p = 0.005) and a higher PaO2/FiO2 ratio after one hour of ventilation (ORa = 0.98 per point; CI 95%, 0.97-0.99; p < 0.001) were protector factors. Conclusions. In Spain, NIV is widely used but it may continue to be underused in COPD and APE. The diagnosis of pneumonia or ARDS was an independent predictive risk factor. Admission in an ICU with NIV in more than 50 patients/year also have higher PaO2/FiO2 ratio after one hour of ventilation were predictive factors of success(AU)

Hipotermia grave como complicación de cetoacidosis diabética / Severe hypothermia as a complication of diabetic ketoacidosis

Se sabe que la diabetes mellitus se acompaña de una serie de alteraciones metabólicas, cardiovasculares y de las funciones neuronales. La cetoacidosis diabética es una de las 3 complicaciones potencialmente mortales de la diabetes mellitus junto a la hipoglucemia y el coma hiperosmolar, y aparece fundamentalmente en pacientes con diabetes mellitus tipo 1 (DM1) o insulinodependientes. Por otra parte, es conocido que algunos pacientes con cetoacidosis diabética presentan una temperatura corporal baja, incluso cuando hay una infección. Sin embargo, no es frecuente que coexista con una situación clínica de hipotermia grave. Presentamos el caso de un paciente que ingresó en nuestra unidad de cuidados intensivos en coma, con cetoacidosis diabética e hipotermia grave (27,6 °C). Revisamos la fisiopatología y el tratamiento de ambas complicaciones cuya asociación es poco frecuente en la práctica clínica habitual (AU)

Análisis de las técnicas continuas de sustitución renal en pacientes críticos con insuficiencia renal aguda / Continuous renal replacement therapies in critically-ill patients with acute renal failure

Fundamento. El fallo renal agudo (FRA) se asocia frecuentemente al síndrome de disfunción multiorgánica (SDMO) en los pacientes críticos. El uso de técnicas continuas de sustitución renal (TCSR) fue descrito por primera vez hace unos 20 años. Analizamos aquí nuestra experiencia valorando los factores pronósticos y la evolución clínica de los pacientes. Pacientes y métodos. Se realizó un estudio descriptivo, observacional y retrospectivo de todos los pacientes críticos con FRA tratados con TCSR, durante el período comprendido entre enero de 1996 y diciembre de 2000. Se recogieron datos demográficos y clínicos, y se realizó un análisis estadístico descriptivo, comparativo y de regresión logística para el estudio de los factores de riesgo relacionados con la mortalidad. Resultados. Fueron evaluados 73 pacientes. La media de edad fue 61 años (intervalo, 17-79), el 62 per cent eran varones, el APACHE II medio fue de 24 (8) y el SAPS II medio fue de 65 (16). La mortalidad global alcanzó el 86,3 per cent. Mediante regresión logística el riesgo de muerte fue más alto en los pacientes con complicaciones relacionadas con la técnica (OR = 2,00; IC del 95 per cent, 1,763-250,0; p = 0,016) y más bajo en pacientes con diuresis residual mayor (OR = 0,995; IC del 95 per cent, 0,990-0,999; p = 0,028). Conclusiones. La mortalidad del FRA que acompaña al SDMO sigue siendo elevada. Las TCSR pueden ser útiles en estos pacientes. En nuestra unidad la ausencia de complicaciones relacionadas con la técnica y la mayor diuresis residual se relacionan con una menor mortalidad. (AU)

[Microbiological study via occluded telescopic catheter in patients under mechanical ventilation and suspected of pneumonia. Clinico-bacteriological follow up of the cases]. / Estudio microbiológico mediante catéter telescópico ocluido en pacientes bajo ventilación mecánica y sospecha de neumonía. Seguimiento clínico-bacteriológico de los casos.

Pneumonias related to mechanical ventilation pose a serious diagnostic challenge and are responsible for elevated mortality. Conventional diagnostic methods are of little help. The introduction of invasive techniques such as bronchial catling via an occluded telescopic catheter (OTC) has proven to be an important advance in diagnosis and therapy. We have compared the bacteriological results obtained using OTC with those using conventional diagnostic methods such as tracheobronchial pumps (TBP) and hemocultures, and we have undertaken a bacteriological, clinical follow-up of the cases. Seventy-four patients under mechanical ventilation and suspected of pneumonia were under study. The study consisted to two consecutive phases of collecting bacteriological samples throughout the patient's evolution. A total of 121 fibrobronchoscopies were performed. The sensitivity obtained with OTC was 76%, and the specificity was 100%. The two techniques, OTC and TBP, coincided in 38% of the cases. According to the bacteriological results obtained with OTC, the antibiotic treatment was modified in 44.5% of the patients. The sensitivity of the OTC was significantly less in those patients were the last doses of antibiotic was administered within two hours of performing the procedure. The procedure of gathering secretions from the inferior respiratory tract with OTC possesses greater sensitivity and diagnostic specificity in patients with mechanical ventilation and pulmonary infiltrates and improves the diagnosis performed by other conventional and routine techniques such as TBA and hemocultures.

[Tetanus in the Murcia region: the clinico-epidemiological characteristics of 150 cases]. / Tétanos en la Región de Murcia: características clínico-epidemiológicas de 150 casos.

150 tetanus cases registered on the region of Murcia have been retrospectively analyzed, they have been collected from the patients admitted at a Intensive Care Unit during a period of 18 years; the clinical together with the epidemiological features, as well as their variations, have been studied through out the years. The impact of a vaccination program in adults which was performed in our region during 1981 has been also evaluated in relationship with the incidence of disease and the economical cost of it. Incidence remained homogeneous until 1982, from that date on a sudden decrease on the number of cases was observed, related with the vaccination program [Period previous to the vaccination program: mean 10 cases/year, versus 5 cases/year since it was started (p < 0.001)]. Regarding the epidemiological characteristics, it is remarkable the shift of the disease toward a more advanced age of onset together with a predominance on females beginning in 1978, but without reaching statically significance. More frequent route of infection is nowadays the intramuscular suppurative injection. Besides this fact the severity of the cases have been increasing (from 59% to 71%, p < 0.005), which has determined that the global mortality of the disease remains almost the same (38%). Mortality has no relationship with age, but is related with being a female (p < 0.05), with intramuscular injection as route of infection (p < 0.025), with the clinical stage (p < 0.001) and with a short incubation period (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative study of protected alveolar lavage versus occluded telescopic catheter in patients with suspected pneumonia and under mechanic ventilation]. / Estudio comparativo del lavado alveolar protegido frente al catéter telescópico ocluido en pacientes con sospecha de neumonía y en ventilación mecánica.

BACKGROUND: The pneumonias associated to mechanical ventilation present great difficulty in diagnosis and have a high mortality. The invasive diagnostic technique of choice in these patients is bronchial curettage by a double telescopic catheter with distal occlusion (OTC) based on its good sensitivity/specificity relation. Recently, the use of a variant of the classical bronchoalveolar lavage (BRL), bronchoalveolar lavage or protected alveolar lavage (PAL) has appeared in the diagnosis of conventional bacterial pneumonia. This new technique provides good specificity of OTC by its use with "protected" catheters and a high sensitivity due to exploration of a greater area of the lung. METHODS: Twenty patients receiving mechanical ventilation (MV) suspected of pneumonia in whom 21 fibrobronchoscopies (FB) were performed with OTC and PAL were studied with quantification of the cultures obtained being carried out. The OTC was performed according to the usual technique and PAL by the instillation of 40 ml of saline serum administered through a Combicath type catheter. RESULTS: OTC and PAL provided diagnostic results which coincided in 8 cases: the same germs were isolated at significant concentrations in six patients and in the two remaining cases direct immunofluorescence for Legionella was positive. PAL was diagnosed in 4 more cases with the diagnosis of viral inclusion bodies being possible in one upon cytologic examination. The count of cells with intracellular bacteria (ICB) was greater than 7% and was always related with positivity in the PAL. CONCLUSIONS: A greater sensitivity was observed with the protected alveolar lavage technique. Moreover, this technique makes virologic investigation and the counting of cells with intracellular bacteria, which may be a marker of rapid diagnosis of bacterial pneumonia, possible.