Neumonía grave por Pneumocystis jiroveci en paciente con enfermedad de Crohn y tratamiento con adalimumab / Pneumocystis jiroveci pneumonia in a Crohn’s disease patient treated with adalimumab

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Ventilación mecánica no invasiva. Fundamentos y aplicación / No disponible

Objetivo: dar a conocer la ventilación mecánica no invasiva (VMNI) en el ámbito de la medicina paliativa. Material y método: revisamos las bases de datos PubMed con estas palabras clave: (non invasive ventilation) AND ("respiratory support" OR "interface" OR "mechanical ventilation" OR "acute respiratory failure" OR "do nat intubate" OR "end life care"), Los criterios de inclusión fueron: trabajos que describen los fundamentos de este soporte ventilatorio, sus indicaciones y complicaciones, preferentemente para pacientes hospitalizados con hipoxemia aguda. Incluimos también estudios que nos parecieron relevantes y que habían sido citados en los trabajos seleccionados. Priorizamos aquellos estudios recientes que describen más claramente la metodología de aplicación de la técnica, las guías de sociedades científicas o fruto de conferencias consenso y los que hacen referencia a pacientes con decisión de no intubar. En la revisión incluimos también tratados y revistas de nuestro ámbito iberoamericano que, sin estar indexadas, publican con asiduidad sobre VMNI con un abordaje interdisciplinar. Excluimos los estudios que sólo abordan terapia con mascarilla nasal, en domicilio, en patología crónica no agudizada, o en pacientes pediátricos, así como estudios experimentales, con poblaciones pequeñas o relativos a patologías muy infrecuentes. Resultados: la búsqueda en la base electrónica PubMed ofreció 732 publicaciones. Con los criterios de selección referidos nos quedamos con 39 citas bibliográficas de las cuales destacamos 4 trabajos de revisión, 2 guías y 5 capítulos de libro. Los demás son originales entre los que se incluyen 7 trabajos sobre cuidado de pacientes con patologías en estadio avanzado o con decisión de no intubar. Como resultados más destacados podemos señalar que los nuevos respiradores específicos y las modernas interfases permiten aplicar VMNI con buena tolerancia y escasos riesgos. El paciente es capaz de comunicarse, expectorar, deglutir y mantiene intactos sus mecanismos de defensa. Conclusiones: la VMNI constituye una técnica útil también en cuidados de pacientes al final de la vida. La VMNI supone una alternativa a la intubación traqueal cuando esta es rechazada por el paciente o es considerada una medida desproporcionada que se debe limitar (AU)

Aim: to offer an overview of non-invasive mechanical ventilation (NIMV) in palliative medicine. Material and method: a PubMed literature search was developed. The key words used in the search strategy were: (non invasive ventilation) AND ("respiratory support" OR "interface" OR "mechanical ventilation" OR "acute respiratory failure" OR "do not intubate" OR "end life care"). Inclusion criteria were: papers focused on methodological aspects to show the background for application, characteristics of the technique, indications and adverse effects, and acute hypoxemic inpatient use. Other key studies quoted in the selection were included. Recent papers on methodological aspects, consensus guidelines, and those on do-not-intubate order were selected. Other papers form our Ibero-American culture -however non indexed- fitting the inclusion criteria were also included. Studies excluded: exclusively nasal mask use, home care, non acute problems, experimental studies, pediatric patient, small simple surveys, and infrequent illness. Results: we found 732 papers from PubMed but only 39 met the inclusion criteria. We can include 4 revisions, 2 guidelines and 5 book chapters. The rest were original papers including 7 surveys on NIMV in advanced stage of illness. As key results we can report that new ventilators and modern interfaces get INMV application with good acceptance and a low risk. Patients are able to communicate, cough, and swallow, and defence mechanisms remain intact. Conclusions: NIMV is a useful tool for end-of-life care NIMV is an alternative to tracheal incubation, especiaIly in patients who refuse invasive therapies or when those are considered inadequate (AU)

[Identification of patients with a high risk of needing prolonged mechanical ventilation after coronary surgery]. / Identicación de pacientes con mayor riesgo de precisar ventilación mecánica prolongada tras cirugía coronaria.

OBJECTIVES: To identify patients at greater risk of developing respiratory complications, defined as the need for mechanical ventilation (MV) longer than 48 h, following revascularization surgery. MATERIAL AND METHODS: This was a prospective analysis of 39 variables in 107 consecutive operations taking place over 9 months. We studied the association of these variables with the need for prolonged MV after surgery, by way of single variable and multivariate analysis. RESULTS: The incidence of prolonged MV was 7.7% and the 25% rate of mortality in the group of patients with this complication was significantly higher than the 0% mortality in the remaining patients. After single variable analysis of the data, the following variables were more significantly (p < 0.01) associated with the need for postoperative MV longer than 48 h: presence of other cardiac lesions other than coronary disease, performance of other heart surgery along with the coronary revascularization, surgical complications, high left auricular pressure soon after surgery. The variables found to have the highest independent predictive value based on the multivariate analysis were performance of other heart surgery along with the coronary revascularization and surgical complications. CONCLUSION: Our study indicates that the variables that point to poor left ventricular function and negative repercussions on extracorporeal circulation are associated with a greater incidence of prolonged MV after coronary surgery. Keeping these variables in mind allows high risk patients to be identified. More extensive monitoring of breathing function and therapeutic measures can then be implemented for better postoperative management.

[The evaluation of enteral nutritional support in the critical patient]. / Valoración del soporte nutricional enteral en el paciente crítico.

UNLABELLED: A prospective study of 40 patients for a period of 9 months was conducted, in order to evaluate the tolerance, clinical evolution and nutritional parameters in critical patients on enteral nutrition. In all cases, nutrients were administered enterally, by nasogastric tube and the administration method selected was continuous perfusion in most cases. 78.5 +/- 17% of estimated Kcal. were administered. During the study, the following aspects were studied: fasting time, type of diet, time during which enteral nutrition (EN) was maintained and reason for suspension, degree of derivation using nasogastric tube (NGT), number of bowel movements per day, antibiotic therapy ad gastric protection drugs as well as drugs administered for supporting mechanical ventilation and the evolution of the patient. Evolutional controls of the nutritional state were also conducted. Tolerance was seen to be good, especially in patients on continuous perfusion. With regard to the evolution of nutritional parameters, we observed maintenance of proteic levels with a slight recovery of retinol-binding protein (RBP) and no statistically significant differences between patients who died and those with a favourable development. The level of oligoelements was maintained, although below normal levels. CONCLUSIONS: EN is the ideal selection for the nutritional support of critical patients with functionally usefull gastrointestinal tracts. A good digestive tolerance was observed, and proteic levels maintained were similar to the initial ones, although with this type of diet, we recommend an additional intake of iron.

[Impact of surgical aggression and postoperative septic problems on fibronectin levels]. / Repercusión de la agresión quirúrgica y de problemas septicos postoperatorios en los niveles de fibronectina.

The following study has been carried out in order to assess the repercussion of surgery on fibronectin (F) levels and its course, whether or not septic complications are presented. The F, albumin (ALB), prealbumin (PREALB), retinol binding protein (RBP) and alpha-1-glycoprotein (GLYCO) levels were controlled in 37 patients (29 undergoing scheduled digestive tract surgery and 8 undergoing heart surgery), through preoperative and postoperative tests every three days. A group of 40 healthy controls was taken as reference. Group I contained 19 patients free of septic complications, statistically significant changes were observed in PREALB and RBP levels but not in F, although a decrease was observed which return to normal by the third test. Group II contained 18 patients which were subdivided into: a) 12 patients suffering from brief septic complication without known focus of infection and, b) 6 patients suffering from more severe septic complication with known focus of infection. The IIA subgroup showed a significant decrease in all protein levels, returning to normal levels by the sixth or seventh day. Subgroup IIB showed lower F levels, which did not return to normal before the ninth day. CONCLUSION. Preoperative controls were similar in I and IIa, while IIB showed significantly lower values. Although F decreased in the first preoperative control, it was not statistically significant. Patients not suffering from complications showed F recuperation within the first week, which was not the case of septic patients. Due to the wide number of functions of F and of the factors that influence it, we believe it should not be interpreted on a single basis a nutritional parameters.