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)

Effects of early use of atenolol or captopril on infarct size and ventricular volume: A double-blind comparison in patients with anterior acute myocardial infarction.

BACKGROUND: beta-Blockers and ACE inhibitors reduce early mortality when either one is started in the first hours after myocardial infarction (MI). Considering the close correlation between morphological changes and prognosis, we aimed to investigate whether the benefit of both beta-blockers and ACE inhibitors might reside in a similar protective effect on infarct size or ventricular volume. METHODS AND RESULTS: In a randomized, double-blind comparison between early treatment with captopril or atenolol in 121 patients with acute anterior MI, both drugs showed a similar reduction in mean blood pressure. However, only the atenolol-treated patients showed a significant early reduction in heart rate. Infarct size, obtained from the perfusion defect in resting single photon emission imaging, was higher in captopril-treated patients than in atenolol-treated patients: 29.8+/-12% versus 20.8+/-12% (P:<0.01) by polar map and 28.3+/-13% versus 20.0+/-13% (P:<0.01) by tomography. Changes from baseline to 1 week and to 3 months in ventricular end-diastolic volume, assessed by echocardiography, were as follows: 58+/-14 versus 64+/-19 (P<0.05) and 65+/-21 mL/m(2) (P<0.05), respectively, with captopril, and 58+/-18 versus 64+/-18 (P<0.05) and 69+/-30 mL/m(2) (P<0.05), respectively, with atenolol. Neither group showed significant changes in end-systolic volume. Among patients with perfusion defect >18% (n=51), those treated with atenolol showed a significant increase of end-systolic and end-diastolic ventricular volumes, whereas captopril-treated patients did not. CONCLUSIONS: Although early treatment with atenolol or captopril results in similar overall short- and medium-term preservation of ventricular function and volumes, in patients with larger infarctions, a beta-blocker alone does not adequately protect myocardium from ventricular dilatation.

[Intracranial hemorrhage following thrombolytic therapy in acute myocardial infarct]. / Hemorragia intracraneal tras la terapéutica trombolítica en el infarto agudo de miocardio.

INTRODUCTION: Intracranial hemorrhage in acute myocardial infarction, under thrombolytic therapeutic, ranges from 0.3 to 3% in different trials. We carried out a study to stabilised the incidence of this complication in ours patients, as well as to analyze its characteristics and asses the presence the predictive factors. METHODS: We retrospectively reviewed 997 consecutive patients with acute myocardial infarction treated with thrombolytic agents. We used two different protocols in two consecutive periods of time. Protocols differ in the age of the patients, the thrombolytic agent and its interval of applications. We analyze the intracranial hemorrhage incidence rate in each period, as well as its relations with the age of the patients, the sex and the thrombolytic agent used. We also analyze the possible predictive risk factors: cerebral-vascular disease, hypertension, diabetes, etc. RESULTS: The overall rate of intracranial hemorrhage was 1.6%, higher in the patients of the second period (0.9% vs 1.9%, p = NS). The age over 70 years don't show a significant increase of this incidence (1.7% vs 1.5%). The APSAC group have shown a greater rate of hemorrhage (4%) than streptokinase (0.8%) and rTPA (1.2%). Cerebral-vascular disease and hypertension background were the two factors more frequently related to hemorrhage. The mortality rate was 68.7%. CONCLUSION: The intracranial hemorrhage is a severe complication of thrombolytic therapy with a relative low incidence, but in our experience, higher than described in multicenter studies. There are several factors related that we would to take into account when is applied this therapy.

[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.