[Nutritional support response in critically ill patients; differences between medical and surgical patients]. / Respuesta al soporte nutricional de una población de pacientes críticos; diferencias entre pacientes médicos y quirúrgicos.

OBJECTIVE: To assess the nutritional response of a group of critically ill patients, as well as the differences in the response to nutritional support between medical and surgical patients. METHODS: One-year long retrospective study including critically ill patients on artificial nutrition for 7 days. Throughout the first week, three nutritional biochemical controls were done that included albumin, prealbumin, transferrin, cholesterol, and electrolytes. Other data gathered were: nutritional risk index, age, gender, weight, height, APACHE, delay of onset of nutritional support, access route, predicted and real caloric intake, medical or surgical patient, hospital stay, duration of the central venous catheter, urinary tube, and/or mechanical ventilation, incidence and density of incidence of nosocomial infections. RESULTS: Sixty-three patients were studied, 30 (47%) medical and 33 (53%) surgical/trauma patients, with a usage of EN higher among medical patients (16/30, 53% vs. 5/33, 15%), PN higher among surgical patients (25/33, 76%), and mixed nutrition similar in both groups (5 medical and 3 surgical patients) (p = 0.001). There were no differences between medical and surgical patients regarding: both predicted and real caloric and nitrogenous intake, APACHE, delay of onset of nutrition, phosphorus, magnesium or glucose levels, mortality and incidence of nosocomial infections. There were no differences either in hospital stay or use of mechanical ventilation, although these tended to be lower in surgical patients. The baseline biochemical parameters did not show differences between both groups, although they were worse among surgical patients. These patients presented during the study period steady albumin levels with improvement in the remaining parameters, whereas medical patients showed a decrease in albumin and transferrin levels, steady prealbumin levels, and slightly improvement in cholesterol levels. CONCLUSIONS: We have observed higher usage of PN among surgical patients, which showed worse baseline nutritional biochemical parameters and responded better to nutritional support and having a trend towards shorter hospital stay and lower mechanical ventilation use than medical patients. We have not observed differences regarding the mortality or nosocomial infection.

Respuesta al soporte nutricional de una población de pacientes críticos; diferencias entre pacientes médicos y quirúrgicos / Nutritional support response in critically ill patients; differences between medical and surgical patients

Objetivo: Evaluación de la respuesta nutricional de un grupo de pacientes críticos, así como el análisis de las diferencias en la respuesta al soporte nutricional, entre pacientes médicos y quirúrgicos. Métodos: Estudio retrospectivo durante un año, incluyendo los pacientes críticos con nutrición artificial durante 7 días. Se realizaron tres controles bioquímicos nutricionales a lo largo de la primera semana, que incluían albúmina, prealbúmina, transferrina, colesterol y electrolitos. Se recogieron, además: índice de riesgo nutricional, edad, sexo, peso, talla, APACHE, retraso del inicio del soporte nutricional, vía de acceso, aporte calórico teórico y real, enfermo médico o quirúrgico, estancia, duración de catéter venoso central, sonda urinaria y/o ventilación mecánica, incidencia y densidad de incidencia de infecciones nosocomiales. Resultados: 63 pacientes estudiados, 30 médicos (47%) y 33 quirúrgicos/traumáticos (53%) siendo la utilización de NE superior en médicos (16/30, 53% vs 5/33, 15%), la de NP en quirúrgicos (25/33, 76%) y la mixta similar en ambos (5 médicos y 3 quirúrgicos) (p = 0,001). No hubo diferencias entre pacientes médicos y quirúrgicos en: aporte calórico y nitrogenado teóricos ni reales, APACHE, retraso en inicio de nutrición, valores de fósforo, magnesio y glucosa, mortalidad e incidencia de infecciones nosocomiales. Tampoco en días de estancia y ventilación mecánica, aunque tendieron a ser menores en pacientes quirúrgicos. Los parámetros bioquímicos iniciales de ambos grupos mostraron diferencias, siendo peores en los enfermos quirúrgicos. Estos presentaron, en el periodo de estudio, un mantenimiento de la albúmina y mejoras del resto de los parámetros, mientras que los médicos mostraron una caída de la albúmina y transferrina, un mantenimiento de la prealbúmina y discreta mejoría del colesterol. Conclusiones: Hemos observado un mayor uso de la NP en pacientes quirúrgicos, que presentan peores valores bioquímicos nutricionales iniciales, que responden mejor al soporte nutricional y que presentan una tendencia a una menor estancia y una menor duración de ventilación mecánica frente a los pacientes médicos. No hemos observado diferencias en mortalidad ni en infección nosocomial (AU)

Objective: To assess the nutritional response of a group of critically ill patients, as well as the differences in the response to nutritional support between medical and surgical patients. Methods: One-year long retrospective study including critically ill patients on artificial nutrition for 7 days. Throughout the first week, three nutritional biochemical controls were done that included albumin, prealbumin, transferrin, cholesterol, and electrolytes. Other data gathered were: nutritional risk index, age, gender, weight, height, APACHE, delay of onset of nutritional support, access route, predicted and real caloric intake, medical or surgical patient, hospital stay, duration of the central venous catheter, urinary tube, and/or mechanical ventilation, incidence and density of incidence of nosocomial infections. Results: Sixty-three patients were studied, 30 (47%) medical and 33 (53%) surgical/trauma patients, with a usage of EN higher among medical patients (16/30, 53% vs. 5/33, 15%), PN higher among surgical patients (25/33, 76%), and mixed nutrition similar in both groups (5 medical and 3 surgical patients) (p = 0.001). There were no differences between medical and surgical patients regarding: both predicted and real caloric and nitrogenous intake, APACHE, delay of onset of nutrition, phosphorus, magnesium or glucose levels, mortality and incidence of nosocomial infections. There were no differences either in hospital stay or use of mechanical ventilation, although these tended to be lower in surgical patients. The baseline biochemical parameters did not show differences between both groups, although they were worse among surgical patients. These patients presented during the study period steady albumin levels with improvement in the remaining parameters, whereas medical patients showed a decrease in albumin and transferrin levels, steady prealbumin levels, and slightly improvement in cholesterol levels. Conclusions: We have observed higher usage of PN among surgical patients, which showed worse baseline nutritional biochemical parameters and responded better to nutritional support and having a trend towards shorter hospital stay and lower mechanical ventilation use than medical patients. We have not observed differences regarding the mortality or nosocomial infection (AU)

Resultados del soporte nutricional en una UCI polivalente / Nutritional support outcomes in critical care

Objetivos: Revisar el efecto de nuestras practicas habituales de soporte nutricional en pacientes críticos y establecer nuevas hipótesis de trabajo. Métodos: Estudio retrospectivo observacional sobre pacientes críticos sometidos a nutrición artificial en el período de un año. Se describe el protocolo de soporte nutricional y se estudian las siguientes variables: APACHE II, retraso en el inicio del soporte nutricional, la vía de administración, el aporte calórico durante la primera semana de soporte nutricional, tipo de paciente, estancia en la unidad, incidencia de infección nosocomial, presencia de complicaciones gastrointestinales y mortalidad. Se estudian los resultados obtenidos y las posibles relaciones entre el tiempo de inicio, la vía de administración y el aporte calórico con los resultados: mortalidad, infección nosocomial, duración de la ventilación mecánica y estancia en la Unidad. Resultados: 102 pacientes que recibieron soporte nutricional fueron seleccionados para el estudio. Estos pacientes mostraron una mayor gravedad, mortalidad y complicaciones infecciosas que los pacientes críticos no sometidos a soporte nutricional. La nutrición enteral fue utilizada en el 41% de los casos, la parenteral en el 40% y la nutrición combinada en el 19%. El soporte nutricional se inició a los 3,1 ± 1,9 días de media, existiendo diferencias entre los pacientes que sobrevivieron y los que no (2,82 ± 1.65 vs 3,74 ± 2,33 días). Los pacientes recibieron el 58 ± 28% de sus requerimientos durante la primera semana de soporte nutricional y no se encontró relación del aporte calórico con la mortalidad, aunque sí con la incidencia de infección nosocomial. Hubo diferencias entre la vía de administración y los siguientes datos: tipo de paciente, aporte calórico, la estancia en UCI y la duración de la ventilación mecánica. Conclusiones: El conjunto de pacientes sometido a soporte nutricional, son pacientes más graves y con peores resultados que los pacientes sin indicación de soporte nutricional. En nuestro estudio el inicio precoz del soporte nutricional, se asoció con una menor mortalidad, aunque no con una menor incidencia de complicaciones infecciosas. El aporte calórico fue bajo, especialmente en pacientes con nutrición enteral, aunque no se relacionó con la mortalidad. Obtuvimos unos mejores resultados clínicos con nutrición parenteral que con la enteral o la parenteral suplementaria. La nueva hipótesis que planteamos es si un aporte calórico moderado y precoz podría asociarse a mejores resultados clínicos, independientemente de la ruta de administración del soporte nutricional (AU)

Background & aims: To revise the effect of our nutritional support practices on outcomes from critical care patients and propose new study hypothesis. Methods: Retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, through a year time, in an Intensive Care Unit. The nutritional support practices are described. Severity of illness (Simplified Acute Physiology Score II), timing and route of nutritional support, prescribed and delivered daily caloric intake for a maximum of 7 days, medical or surgical patient, length of stay in ICU, incidence rate and incidence density of nosocomial infections, and presence of gastrointestinal complications were recorded. Relationships between timing and route of nutritional support and percentage of received/ prescribed calories with mortality, nosocomial infections, days of mechanical ventilation and length of stay in the Intensive Care Unit were studied. Results: 102 patients of our intensive care patients received nutritional support and were selected for the study. EN was used in 42 patients (41%), 41 (40%) received TPN and 19 patients (19%) received mixed nutrition. Timing of nutritional support showed a mean of 3.1 ± 1.9 days and was statistically different between patients who survived or died (2.82 ± 1.65 vs. 3.74 ± 2.33 days). Patients received 58 ± 28% of their requirements but this data did not show any difference with mortality and morbidity. There was a statistical difference between the route of nutrition and the following data: type of patient, caloric intake in the study period, length of stay in ICU and days of mechanical ventilation. Conclusions: Our study demonstrates that nutritional support patients are more severely ill than nonnutritional support patients. Timing of nutritional support was shorter in survivors. Our study confirms a low caloric input in the critically ill patient during the first week of illness, especially in the enteral nutrition group. However this finding was not associated with mortality or morbidity. Parenteral route did show better clinical outcomes than enteral or mixed nutrition. Our findings suggest that a moderate and early caloric intake could obtain better outcomes, independently of the route of nutritional support (AU)

[Nutritional support outcomes in critical care]. / Resultados del soporte nutricional en una UCI polivalente.

BACKGROUND & AIMS: To revise the effect of our nutritional support practices on outcomes from critical care patients and propose new study hypothesis. METHODS: Retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, through a year time, in an Intensive Care Unit. The nutritional support practices are described. Severity of illness (Simplified Acute Physiology Score II), timing and route of nutritional support, prescribed and delivered daily caloric intake for a maximum of 7 days, medical or surgical patient, length of stay in ICU, incidence rate and incidence density of nosocomial infections, and presence of gastrointestinal complications were recorded. Relationships between timing and route of nutritional support and percentage of received/ prescribed calories with mortality, nosocomial infections, days of mechanical ventilation and length of stay in the Intensive Care Unit were studied. RESULTS: 102 patients of our intensive care patients received nutritional support and were selected for the study. EN was used in 42 patients (41%), 41 (40%) received TPN and 19 patients (19%) received mixed nutrition. Timing of nutritional support showed a mean of 3.1 ± 1.9 days and was statistically different between patients who survived or died (2.82 ± 1.65 vs. 3.74 ± 2.33 days). Patients received 58 ± 28% of their requirements but this data did not show any difference with mortality and morbidity. There was a statistical difference between the route of nutrition and the following data: type of patient, caloric intake in the study period, length of stay in ICU and days of mechanical ventilation. CONCLUSIONS: Our study demonstrates that nutritional support patients are more severely ill than nonnutritional support patients. Timing of nutritional support was shorter in survivors. Our study confirms a low caloric input in the critically ill patient during the first week of illness, especially in the enteral nutrition group. However this finding was not associated with mortality or morbidity. Parenteral route did show better clinical outcomes than enteral or mixed nutrition. Our findings suggest that a moderate and early caloric intake could obtain better outcomes, independently of the route of nutritional support.

A retrospective study about the influence of early nutritional support on mortality and nosocomial infection in the critical care setting.

BACKGROUND & AIMS: To determine whether early nutritional support reduces mortality and the incidence of nosocomial infection, in critically ill patients in the current practice. METHODS: A retrospective observational study was conducted in all critically ill patients who had been prescribed nutritional support, throughout one year, in an Intensive Care Unit. The time to start and the route of delivery of nutritional support were determined by the attending clinician's assessment of gastrointestinal function and hemodynamic stability. Age, gender, severity of illness, start time and route of nutritional support, prescribed and delivered daily caloric intake for the first 7 days, whether they were a medical or surgical patient, length of stay in ICU, incidence rate of nosocomial infections and ICU mortality were recorded. Patients were classified according to whether or not they received nutritional support within 48 h of their admission to ICU and Binary Logistic Regression was performed to assess the effect of early nutritional support on ICU mortality and ICU nosocomial infections after controlling for confounders. RESULTS: Ninety-two consecutive patients were included in the study. Start time of nutritional support showed a mean of 3.1 ± 1.9 days. Patients in the early nutritional support group had a lower ICU mortality in an unadjusted analysis (20% vs. 40.4%, p = 0.033). Early nutritional support was found to be an independent predictor of mortality in the regression analysis model (OR 0,28; 95% confidence interval, 0.09 to 0,84; p = 0.023). Our study did not demonstrate any association between early nutritional support and the incidence of nosocomial infection (OR 0.77; 95%. confidence interval, 0.26 to 2,24; p = 0.63), which was related to the route of nutritional support and the caloric intake. The delayed nutritional support group showed a longer length of stay and nosocomial infections than the early group, although these differences were not statistically significant. CONCLUSIONS: Our study shows that early nutrition support reduces ICU mortality in critically ill patients, although it does not demonstrate any influence over nosocomial infection in the current practice in intensive care.

Traumatismo craneoencefálico: valor pronóstico de los marcadores de hipercoagulabilidad y fibrinólisis / Head trauma: prognostic value of hypercoagulability and fibrinolysis markers

Objetivo. Estudiar la activación hemostática en los enfermos con traumatismo craneoencefálico (TCE) y su relación con la gravedad y el pronóstico. Diseño. Estudio de cohortes prospectivo con un período de inclusión de 28 meses y seguimiento evolutivo a los 6 meses. Ámbito. Un Servicio de Medicina Intensiva de un Hospital Universitario. Pacientes y método. Pacientes con TCE único, con menos de 6 horas de evolución al ingreso y que no presentaran situaciones que interfirieran con la coagulación. Intervenciones. Realizamos dos extracciones sanguíneas de vena periférica (al ingreso y a las 24 horas). Determinamos fragmentos de trombina 1+2 (F1+2), complejo trombina-antitrombina (TAT) y D-dímeros. La gravedad del TCE fue medida mediante Glasgow Coma Score (GCS) y dividimos a los pacientes en dos grupos, TCE grave y moderado-leve. La evolución fue medida mediante Glasgow Outcome Score (GOS), obteniendo dos grupos, buena y mala evolución. Realizamos un análisis estadístico de los resultados mediante ANOVA de dos vías. Resultados. Se incluyeron 45 enfermos. Edad media 46,1; 31 varones. GCS 10,1; SAPS II 32,5. Veintiséis enfermos presentaron TCE leve-moderado y 19 TCE grave. Veintisiete tuvieron mala evolución y 18 buena evolución. Los marcadores fueron más elevados de forma significativa en el grupo de TCE severo frente al grupo TCE levemoderado y el grupo de peor evolución frente al grupo de buena evolución. Conclusiones. F1+2, TAT y D-dímeros están más elevados en pacientes con TCE más grave y peores resultados evolutivos a los 6 meses (AU)

Desviaciones angulares de las extremidades inferiores en la infancia: genu valgo / Angula deviations of the lower limbs in children: genu valgum

El genu valgo consiste en una desviación axial de las extremidades inferiores en el plano frontal que se manifiesta en el niño cómo una deformidad característica “en X” por alteración del ángulo normal de alineación femorotibial. Puede ocasionar dificultad para la marcha y patología degenerativa articular de forma tardía en el adulto. En los casos en los que no se resuelve espontáneamente o produce un alteración significativa de la deambulación, requiere tratamiento ortésico y/o quirúrgico . En este artículo, revisamos los aspectos diagnósticos y terapéuticos más relevantes expuestos en la literatura al respecto (AU)

Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos / Reliability assessment of four ventilators used in critically-ill patients

OBJETIVOS: Comprobar la fiabilidad de cuatro ventiladores empleados en la práctica diaria habitual con enfermos críticos con insuficiencia respiratoria aguda. MÉTODOS: Estudio experimental, realizado con 4 ventiladores y un comprobador de respiradores Bio-Tek® VT.2, ajustado con distintos valores de resistencia y compliancia. Se recogieron las diferencias entre los datos obtenidos por los respiradores y el comprobador, en los volúmenes entregados y la presión teleespiratoria. Se comprobó si las diferencias existentes entre los respiradores y el comprobador podrían ser significativas, y el coeficiente de variación para estudiar la posible desviación de los parámetros programados a lo largo del tiempo. Se calcularon y aplicaron los márgenes de error de los respiradores. RESULTADOS: En situaciones de compliancia y resistencia, parecidas a las que presentan los enfermos con enfermedad pulmonar obstructiva crónica y síndrome de distrés respiratorio agudo, hay diferencias entre los volúmenes corrientes medidos por la monitorización de los respiradores y los entregados al final de sus circuitos respiratorios, aunque apenas se superan los márgenes de error. El coeficiente de variación no fue significativo en ninguna de las situaciones de compliancia y resistencia aplicadas. CONCLUSIONES: Existen diferencias, frente a situaciones de baja compliancia y/o elevada resistencia, entre los volúmenes corrientes monitorizados y los entregados en algunos ventiladores, aunque dichas diferencias sean pequeñas y apenas superen los márgenes de error admitidos para los ventiladores. Los resultados del coeficiente de variación indican una alta capacidad de mantener constantes los parámetros programados a lo largo del tiempo (AU)

OBJECTIVES: Mechanical ventilators are often used in critically-iII patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek® VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end or the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any or the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time (AU)

[Analysis of the reliability of 4 ventilators used in critically ill patients]. / Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos.

OBJECTIVES: Mechanical ventilators are often used in critically-ill patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programmed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end of the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any of the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time.

[Diagnose and predict utility of transcranial Doppler in the serious cerebral anoxia]. / Utilidad diagnóstica y pronóstica del Doppler transcraneal en los casos de anoxia cerebral grave.

INTRODUCTION: In the clinical daily practice, exist multiple situations in which could produce phenomenons of serious hypoxia to encephalic level, normally with important repercussions for the patient. OBJECTIVES: Study if after the existence of a situation of serious encephalic hypoxia, any typical pattern in the exploration transcranial Doppler (TCD) exists, and the possible diagnostic and/or prognostic implications could bear. PATIENTS AND METHODS: We presented 10 patients admitted in our Unit of Intensive Care, for clinical situations in which a situation of encephalic hypoxia took place and to which was practiced a TCD like exploration of encephalic flow. We related the discoveries of the DTC, with the clinical situation, the images of the cerebral computed tomography in three of the patients, and the data of the electroencephalogram in the other seven. Like statistical tool, is used the test of square ji, demanding a confidence interval of the 95%. RESULTS: In all the patients, we found a patron TCD, of high speed mean with low Pulsatility Index. Nine patients died, surviving with serious sequels the last patient. CONCLUSIONS: In our series, we could conclude, that the existence of a patron TCD with high speed mean and with low Pulsatility Index, after an episode of brain hypoxia, its associated to a wrong presage, existing a high risk of death of the patient.

Aparición de trombopenia severa y hemorragia cerebral. Probable relación causa-efecto en el curso clínico de una brucelosis / Appearance of severe thrombopenia and intracerebral hemorrhage. A probable relation cause-effect in clinic course of brucellosis

La brucelosis es una zoonosis causada por microorganismos del género Brucella, transmitidos al hombre por animales domésticos. Puede afectar a cualquier órgano o sistema, y por lo tanto cursar con un amplio espectro de manifestaciones clínicas. Las complicaciones hematológicas son variables y consisten en anemia, leucopenia o trombopenia: En más del 30 por ciento de los casos aparece una discreta plaquetopenia, pero la observación de trombocitopenia grave es un raro hallazgo. En caso de aparecer clínica hemorrágica la localización más frecuente es la púrpura cutáneo-mucosa, seguida por el sangrado digestivo y la epixtasis. Un varón de 23 años, con historia de contacto con ganado ovino y tabaquismo, diagnosticado serológicamente de brucelosis aguda, ingresó en nuestra Unidad de Cuidados Intensivos, debido ã la aparición de trombopenia severa, sangrado en diversas localizaciones y hemorragia cerebral. Aunque la endocarditis es la causa más frecuente de mortalidad en la brucelosis, las complicaciones hematológicas pueden ser severas (AU)