Cuidados intensivos orientados a la donación de órganos. Recomendaciones ONT-SEMICYUC / Intensive care to facilitate organ donation. ONT-SEMICYUC recommendations

Los cuidados intensivos orientados a la donación (CIOD) se definen como el inicio o la continuación de medidas de soporte vital, incluyendo la ventilación mecánica, en pacientes con lesión cerebral catastrófica y alta probabilidad de evolucionar a muerte encefálica, en los que se ha descartado cualquier tipo de tratamiento. Los CIOD incorporan la opción de la donación de órganos permitiendo un enfoque holístico en los cuidados al final de la vida coherente con los deseos y valores del paciente. Si el paciente no evoluciona a muerte encefálica, se deben retirar las medidas de soporte vital valorando la donación en asistolia controlada. Los CIOD respetan el marco ético y legal y contribuyen a aumentar las probabilidades de los pacientes de acceder a la terapia de trasplante, generando salud, incrementando la donación en un 24% con una media de 2,3 órganos trasplantados por donante y contribuyendo a la sostenibilidad del sistema sanitario. Estas recomendaciones ONT-SEMICYUC proporcionan una guía para facilitar una práctica armonizada de los CIOD en las UCI españolas. (AU)

Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs. (AU)

[Intensive care to facilitate organ donation. ONT-SEMICYUC recommendations]. / Cuidados intensivos orientados a la donación de órganos. Recomendaciones ONT-SEMICYUC.

Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs.

Seroprevalencia de anticuerpos frente a virus linfotrópicos humanos (HTLV I y II) en donantes de órganos / Human T lymphotropic virus (HTLV I and II) antibodies seroprevalence among organ donors

No disponible

En respuesta a «Trombectomía mecánica en el ictus isquémico agudo, conociendo nuestros resultados» / In reply to "Mechanical thrombectomy in acute ischemic stroke, knowing our results"

No disponible

Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía / Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature

Objetivo: Valorar si la técnica de embolización urgente del aneurisma cerebral y posterior cirugía del hematoma es segura y eficaz en pacientes con hematoma y signos de hipertensión intracraneal por rotura de aneurisma cerebral. Métodos: Se incluyeron 23 pacientes consecutivos con aneurisma cerebral roto y mal estado clínico debido a un hematoma intracraneal, ambos tratamientos completados en las primeras 4 horas del inicio de la clínica. Todos los pacientes presentaban signos clínicos de hipertensión intracraneal y/o alteración del nivel conciencia, incluido coma por deterioro rostrocaudal. Se valoró la eficacia de la técnica mediante el grado de cierre de los aneurismas y el pronóstico de los pacientes un mes después, y la seguridad, mediante el análisis de las complicaciones de los tratamientos. Resultados: El 91,3% de los pacientes tenía un aneurisma localizado en la arteria cerebral media (ACM). Todos los pacientes presentaban un valor de 4 en la escala de Fisher y de IV-V en la escala de Hunt y Hess. El tiempo medio desde la identificación del aneurisma en la tomografía computarizada hasta la embolización del aneurisma fue de 115 minutos. Se usó balón de remodeling en el 78% de los casos, con el que se logró un cierre adecuado en el 82,6% de los pacientes. Durante la cirugía se colocó un drenaje ventricular en 9 (39,1%) pacientes. Al mes, 13 (56,5%) pacientes eran independientes, con una mortalidad del 13%. No existieron resangrados. Conclusión: En nuestra experiencia, el tratamiento combinado mediante embolización del aneurisma y descompresión quirúrgica con evacuación del hematoma es segura y efectiva, y es una alternativa al tratamiento quirúrgico aislado

Objective: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. Methods: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4 hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. Results: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. Conclusion: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone

Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature. / Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía.

OBJECTIVE: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. METHODS: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. RESULTS: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. CONCLUSION: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone.

Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica / Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit

OBJETIVO: Estudiar los resultados y las complicaciones del tratamiento endovascular (TEV) en pacientes con ictus isquémico agudo ingresados en una unidad de cuidados intensivos (UCI). Analizar los factores que podrían influir en la mortalidad y en el grado de discapacidad al alta y un año después del ictus. DISEÑO: Estudio prospectivo observacional. Ámbito: UCI polivalente. Hospital de tercer nivel. PACIENTES: Sesenta pacientes adultos. Muestra consecutiva. INTERVENCIONES: Ninguna. Variables de interés: Datos epidemiológicos, tiempo desde la clínica inicial hasta el TEV, resultado angiográfico, tiempo de estancia en UCI, días de ventilación mecánica, complicaciones neurológicas, National Institutes of Health Stroke Scale (NIHSS) al ingreso y al alta de UCI, escala de Rankin modificada (mRS) al año de evolución. RESULTADOS: Edad media 68,90±8,84años. Mediana de tiempo hasta el TEV: 180min. Mediana NIHSS al ingreso: 17,5; al alta: 3. Flujo distal en el 90% de los casos. Mediana estancia en UCI: 3días. Ventilación mecánica: 81,7%. Independencia funcional (mRS≤2) 50% al año del ictus. Fallecimientos: 22 (36,6%); 8 (13,3%) en la UCI y el resto durante el primer año. CONCLUSIONES: Las variables asociadas a un peor estado funcional fueron la transformación hemorrágica sintomática, la ausencia de recanalización y las complicaciones durante el procedimiento. La transformación hemorrágica y la hidrocefalia se asociaron a mayor mortalidad. Se consiguió flujo distal en la mayoría de los casos, con una baja tasa de complicaciones. La mitad de los pacientes alcanza independencia funcional al año del ictus

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. Variables of interest: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke

Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit. / Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica.

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. VARIABLES OF INTEREST: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke.

[Up-date in spontaneous cerebral hemorrhage]. / Actualización en hemorragia cerebral espontánea.

Non-aneurismatic spontaneous cerebral hemorrhage or intracranial hemorrhage accounts for 10-15% of total cerebral vascular accidents. Depending on its site it can may be intraparenchymal or intraventricular. The most frequent location is in the basal ganglia and its predominant etiology is poorly-controlled arterial hypertension. In Spain, the incidence of intracerebral hemorrhage is estimated to be 15 cases per 100,000 population/ year, this being more frequent in males over 55 years old. Intracranial hemorrhage is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Cerebral hemorrhage is not a monophasic phenomenon which abates immediately, because the hematoma continues to increase in the first 24 hours. Due to this reason and because of their characteristics of the disease itself, these are critical patients who must be admitted in to Intensive Care Unit where hemodynamic and cardiorespiratory control should be made as well as strict monitoring of the awareness level and remaining neuromonitoring standard parameters. In this paper, we review some aspects of the epidemiology, physiopathology, clinical presentation, diagnosis and the different therapeutic options, performing an up-date on the treatment of intracranial hemorrhage from both the medical and surgical point of view.

Actualización en hemorragia cerebral espontánea / Up-date in spontaneous cerebral hemorrhage

La hemorragia cerebral espontánea no aneurismáticao hemorragia intracraneal supone el 10-15% de todos los ictus y según su localizaciónpuede ser intraparenquimatosa o intraventricular.Su localización más frecuente es en los gangliosde la base, y la etiología predominante es la hipertensión arterial mal controlada. En España laincidencia asciende hasta los 15 casos por cada100.000 habitantes/año, siendo más frecuente envarones mayores de 55 años. La hemorragia intracraneales mucho menos frecuente que el ictusisquémico, pero presenta una mayor mortalidad ymorbilidad, siendo una de las primeras causas dediscapacidad grave. La hemorragia cerebral no es un fenómeno monofásico que ceda inmediatamente,ya que el hematoma continúa aumentando en las primeras 24 horas. Por esta razón, y por las características propias de la enfermedad, son pacientes graves que requieren ingreso en una Unidad de Cuidados Intensivos donde se debe rea lizar la estabilización hemodinámica y cardiorrespiratoria, además de un estricto controldel nivel de conciencia y el resto de parámetroshabituales de neuromonitorización.En el presente artículo se hace un repaso sobrela epidemiología, fisiopatología, presentación clínica,diagnóstico y las diferentes opciones terapéuticas,realizando una actualización sobre el tratamiento de las hemorragias intracraneales, tanto desde el punto de vista médico como quirúrgico

Non-aneurismatic spontaneous cerebral hemorrhageor intracranial hemorrhage accounts for 10-15% of total cerebral vascular accidents. Depending on its site it can may be intraparenchymal or intraventricular. The most frequent location is in the basal ganglia and its predominant etiology is poorly-controlled arterial hypertension. In Spain, the incidence of intracerebral hemorrhage is estimated to be 15 cases per 100,000 population/year, this being more frequent in males over55 years old. Intracranial hemorrhage is lessfrequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Cerebral he morrhage is not a monophasic phenomenon which abates immediately, because the he ma to ma continues to increase in the first 24 hours. Due to this reason and because of their characteristics of the disease itself, these are critical patients who must be admitted in to Intensive Care Unit where hemodynamic and cardiorespiratory control should be made as well as strict monitoring of the awareness level and remaining neuromonitoring standard parameters.In this paper, we review some aspects of theepidemiology, physiopathology, clinical presentation, diagnosis and the different therapeutic options,performing an up-date on the treatment of intracranial hemorrhage from both the medical and surgical point of view

Detección de muerte encefálica mediante monitorización BIS (índice biespectral) / Detection of encephalic death by BIS (bispectral index) monitoring

Objetivo. Valorar el monitor BIS (índice biespectral) como método de detección de muerte encefálica. Diseño. Estudio observacional prospectivo. Ámbito. Unidad de Medicina Intensiva de Hospital Universitario. Pacientes y método. Dieciséis pacientes ingresados de forma no consecutiva en la Unidad de Cuidados Intensivos, con patología neurológica grave, y evolución a muerte encefálica (ME). Se utilizó un monitor BIS, modelo XP y el sensor "BIS Quatro". Se registraron de forma continua los valores de BIS, tasa de supresión (TS), índice de calidad de señal y actividad electromiográfica. Resultados. El diagnóstico de ME se realizó mediante exploración clínica neurológica y electroencefalograma en todos los casos. Adicionalmente, en 11 pacientes, se utilizó el doppler transcraneal. Coincidiendo con el empeoramiento clínico, se objetivó un descenso paulatino del valor BIS, junto con un ascenso en la TS. En todos los pacientes en los cuales se confirmó el diagnóstico de ME, el BIS mostró valores de 0 y TS de 100. Sólo un paciente presentó interferencias, por actividad electromiográfica, detectándose el mismo problema al realizar el electroencefalograma convencional. Tras utilizar un bloqueante neuromuscular, los valores de BIS y TS fueron de 0 y 100 respectivamente. Conclusiones. El BIS es un método no invasivo, sencillo y de fácil interpretación. Todos los pacientes diagnosticados de ME, excepto uno, tenían un valor BIS de 0 y TS de 100, mostrando una perfecta correlación con los otros métodos diagnósticos utilizados. El BIS no puede ser utilizado de forma exclusiva en la confirmación de la ME, pero es una herramienta muy útil, empleada como "señal de alarma", ya que detecta precozmente el inicio del enclavamiento cerebral

Objective. Assess the BIS monitor (Bispectral index) as a detection method of encephalic death. Design. Prospective, observational study. Scope. Intensive Medicine Unit of a University Hospital. Patients and method. Sixteen (16) patients admitted non-consecutively to the Intensive Care Unit, with serious neurological condition and evolution to encephalic death (ED). A BIS monitor, model XP and "BIS Quatro" sensor were used. The BIS, suppression rate (SR), quality index of the signal and electromyographic activity values were recorded continuously. Results. The ED diagnosis was performed by neurological clinical examination and electroencephalogram in every case. In addition, transcranial Doppler was used in 11 patients. Coinciding with clinical deterioration, a slow decrease in the BIS value, together with increase in the SR, was observed. In all the patients in whom ED diagnosis was confirmed, the BIS showed values of 0 and suppression rates of 100. Only one patient had interferences, due to electromyographic activity, the same problem being detected when the conventional EEG was performed. After using a neuromuscular blocker, the BIS and SR values were 0 and 100, respectively. Conclusions. BIS is a non-invasive, simple and easy to interpret method. All patients diagnosed of ED, except one, had a BIS value of 0 and SR of 100, showing a perfect correlation with the other diagnostic methods used. The BIS cannot be used exclusively in the confirmation of ED, however it is a very useful tool, used as "alarm signal", since it detects the onset of cerebral incarceration early

Diagnóstico clínico de muerte encefálica. Prerrequisitos y exploración neurológica / Clinical diagnosis of brain death. Prerequisites and neurologic examination

Para el médico intensivista, realizar un diagnóstico de muerte encefálica (ME) implica tomar decisiones de gran responsabilidad: retirar las medidas de soporte, o valorar la donación de órganos para trasplante. En este trabajo, se repasa el diagnóstico de ME, centrándose fundamentalmente en sus aspectos clínicos e insistiendo en la necesidad de realizar una exploración neurológica sistemática, completa y extremadamente rigurosa. Se detallan los prerrequisitos que ha de presentar el paciente antes de inicial el protocolo diagnóstico, y la exploración neurológica necesaria incluyendo cada uno de los reflejos troncoencefálicos y la prueva de apnea. También, se revisan las características y tipos de actividad motora de origen medular que pueden aparecer en situaciones de ME, así como el período de observación necesarios para realizar dicho diagnóstico (AU)