La oliguria y su contexto / Oliguria and its context

La oliguria fue definida con un volumen urinario (VU) <400 ml/día. Los consensos del Grupo ADQI (Acute Dialysis Quality Initiative) a través del RIFLE y el AKIN (Acute Kidney Injury Network), incluyeron el VU en la estratificación de la injuria renal aguda (IjRA) y consideraron que su medición horaria es un marcador sensible del compromiso de la función renal. El tema central es que el VU y la creatininemia son signos de alarma tardíos en la IjRA. En la presente revisión se refieren la utilidad y limitaciones de los mismos así como de los índices bioquímicos urinarios. Se destaca la importancia de los nuevos biomarcadores de injuria que permitirán implementar medidas terapéuticas tempranas que mejoren la elevada morbimortalidad de la IjRA.

Acuaporinas / Aquaporins

Las acuaporinas constituyen una familia de canales que regulan el trasporte del agua en la membrana de todos los órganos. Desde la descripción de la primer acuaporina por Peter Agre y col., por lo que recibió el Premio Nobel de Química en el 2003, mucha información ha sido obtenida sobre el significado de estos canales proteicos. Están involucradas en múltiples desórdenes como la diabetes insípida nefrogénica, pérdida de la visión, el edema cerebral, la respuesta al ayuno, la intoxicación por arsénico, etc. Su descubrimiento enriqueció la comprensión de la regulación de los volúmenes corporales. En este artículo se hace una breve revisión de los conocimientos actuales sobre las mismas.

Pseudoaneurisma micótico de la arteria carótida extracraneana por infección parafaríngea / Extracranial carotid pseudoaneurysm within a parapharyngeal infection

El 5 por ciento de los aneurismas micóticos (AM) se ubica en el territorio carotídeo y la localización en su sector extracraneal es extremadamente rara...Se presenta un paciente con pseudoaneurisma micótico de la arteria carótida extracraneal secundario a infección parafaríngea, complicado con infarto cerebral y tratado con ligadura de vaso

Pseudoaneurisma micótico de la arteria carótida extracraneana por infección parafaríngea / Extracranial carotid pseudoaneurysm within a parapharyngeal infection

El 5 por ciento de los aneurismas micóticos (AM) se ubica en el territorio carotídeo y la localización en su sector extracraneal es extremadamente rara...Se presenta un paciente con pseudoaneurisma micótico de la arteria carótida extracraneal secundario a infección parafaríngea, complicado con infarto cerebral y tratado con ligadura de vaso(AU)

Sindrome de embolia grasa postraumático con derrame pleural / Postraumatic fat embolism syndrome with pleural effusion

El síndrome de embolia grasa se genera por el pasaje de grasa de la médula ósea o tejidos blandos de los vasos sanguíneos. Es una causa frecuente de mortalidad en pacientes con fractura de huesos largos. Los órganos blanco son el pulmón, la piel y el cerebro pero con frecuencia está ausente uno de ellos (sindrome incompleto) lo que dificulta el diagnóstico. Se presenta un paciente de 31 años con fractura de huesos largos que al tercer día desarrolla hipoxemia severa, infiltrados pulmonares bilaterales en vidrio esmerilado, derrame pleural y plaquetopenia. Con tratamiento de sostén el proceso se autolimitó en ocho días.

Neumonía y distres respiratorio por varicela en un adulto inmunocompetente / Varicella pneumonitis eith acute respiratory distress syndrome in immunocompetent adult

La varicela es una enfermedad prevalente en países desarrollados no obstante contarse con una vacuna efectiva. De evolución benigna en niños, la incidencia en adultos se duplicó en los últimos 20 años y está asociada con mayor número de complicaciones. La neumopatía es la más importante y se refirió una mortalidad de 10-30 por ciento que se eleva a 50 por ciento si es necesaria la asistencia resporatoria mecánica...Se presenta un varón adulto inmunocompetente con neumonía grave y distres respiratorio por varicela, que requirió asistencia respiratoria mecánica.

Sindrome de embolia grasa postraumático con derrame pleural / Postraumatic fat embolism syndrome with pleural effusion

El síndrome de embolia grasa se genera por el pasaje de grasa de la médula ósea o tejidos blandos de los vasos sanguíneos. Es una causa frecuente de mortalidad en pacientes con fractura de huesos largos. Los órganos blanco son el pulmón, la piel y el cerebro pero con frecuencia está ausente uno de ellos (sindrome incompleto) lo que dificulta el diagnóstico. Se presenta un paciente de 31 años con fractura de huesos largos que al tercer día desarrolla hipoxemia severa, infiltrados pulmonares bilaterales en vidrio esmerilado, derrame pleural y plaquetopenia. Con tratamiento de sostén el proceso se autolimitó en ocho días.(AU)

Neumonía y distres respiratorio por varicela en un adulto inmunocompetente / Varicella pneumonitis eith acute respiratory distress syndrome in immunocompetent adult

La varicela es una enfermedad prevalente en países desarrollados no obstante contarse con una vacuna efectiva. De evolución benigna en niños, la incidencia en adultos se duplicó en los últimos 20 años y está asociada con mayor número de complicaciones. La neumopatía es la más importante y se refirió una mortalidad de 10-30 por ciento que se eleva a 50 por ciento si es necesaria la asistencia resporatoria mecánica...Se presenta un varón adulto inmunocompetente con neumonía grave y distres respiratorio por varicela, que requirió asistencia respiratoria mecánica.(AU)

Neumoencéfalo, otitis media y meningitis a neumococo / Pneumocephalus, middle otitis and meningococcic meningitis

La meningitis bacteriana es una enfermedad con alta morbi-mortalidad, el germen prevalente es el Strep pneumoniae y constituye la complicación intracraneal más frecuente de la otitis media aguda en el adulto. La TAC de cerebro es de indicación habitual ante su sospecha, previa a la realización de la punción lumbar, y en el 13 por ciento de los casos, los hallazgos son compatibles con una disrupción de la barrera dural, de la que el neumoencéfaloi (NE) es una de las consecuencias. Se presenta un paciente con meningitis bacteriana aguda por neumococo, otitis media y NE, sin traumatismo, malformación, tumor o cirugía previa

Neumoencéfalo, otitis media y meningitis a neumococo / Pneumocephalus, middle otitis and meningococcic meningitis

La meningitis bacteriana es una enfermedad con alta morbi-mortalidad, el germen prevalente es el Strep pneumoniae y constituye la complicación intracraneal más frecuente de la otitis media aguda en el adulto. La TAC de cerebro es de indicación habitual ante su sospecha, previa a la realización de la punción lumbar, y en el 13 por ciento de los casos, los hallazgos son compatibles con una disrupción de la barrera dural, de la que el neumoencéfaloi (NE) es una de las consecuencias. Se presenta un paciente con meningitis bacteriana aguda por neumococo, otitis media y NE, sin traumatismo, malformación, tumor o cirugía previa(AU)

[Platypnea-orthodeoxia syndrome, atrial septal aneurysm and right hemidiaphragmatic elevation with a right-to-left shunt through a patent foramen ovale]. / Sindrome platipnea-ortodeoxia por foramen oval permeable, aneurisma del septum interauricular y paralisis del hemidiafragma derecho.

Platypnea-orthodeoxia is an uncommon syndrome of dyspnea and hypoxemia induced by upright position, which is subsequently relieved by recumbency. The case reported involved a 75-year-old man with a seven days history of dyspnea in the upright position. The chest radiograph and CT scan demonstrated an elevated right hemidiaphragm. A surface echocardiogram with saline solution showed a patent foramen ovale (PFO) and atrial septal aneurysm. A pulmonary arteriogram was performed showing no evidence of pulmonary embolism and normal pulmonary arterial pressures. Later, he also developed dyspnea in the supine position and a transesophageal echocardiogram with contrast demonstrated a large right to left shunt through a PFO. The closure by a catheter-deployed double-umbrella device caused an immediate improvement in the patient's oxygenation.

[Platypnea-orthodeoxia syndrome]. / Sindrome platipnea-ortodeoxia.

Platypnea-orthodeoxia is an uncommon syndrome of dyspnea and hypoxemia induced by upright posture, which is subsequently relieved by recumbency. Traditionally, this condition has been reported in association with pulmonary, hepatic and cardiac diseases, but the mechanism is different in each situation. In presence of an atrial septal defect, a right to left cardiac shunt resulting as a consequence of redirection of the inferior vena cava flow towards the atrial septum and results in postural hypoxemia. In pulmonary shunts, as in hepatopulmonary syndrome and a-v pulmonary fistulas, the mechanism of hypoxemia is related to the preferential circulation to basal areas of both lungs in the upright position. On the other hand, lung diseases affecting basal areas and increasing the alveolar pressure are related to the development of parenchimal pulmonary shunts with hypoxemia during postural changes, since the dead space, the functional shunt and the hypoxic vascular pulmonary constriction are affected. The autonomic neuropathy may attenuate normal sympathetic vasoconstrictor responses during postural changes, resulting in ventilation-perfusion mismatching and hypoxemia. Clinical and therapeutic aspects of this sindrome are provided.

[Maternal morbidity and perinatal mortality in HELLP syndrome. Multicentric studies in intensive care units in Buenos Aires area]. / Complicaciones maternas y mortalidad perinatal en el síndrome HELLP. Registro multicéntrico en unidades de cuidados intensivos del área Buenos Aires.

We analyzed the clinical characteristics, complications, severity, and maternal and fetal survival of patients suffering from HELLP syndrome (Hemolysis, Elevated Liver enzymes level, Low Platelet count) requiring admission to the intensive care unit in four hospitals from Buenos Aires area, Argentina. Data was revised in the charts from March 1997 to March 2003 and 62 patients were included in the study. During the second half of pregnancy or immediate puerperal period, diagnostic criteria were defined on the basis of preeclampsia and the following laboratory abnormalities: platelet count nadir <150,000/mm3, serum hepatic aminotransferases >70 UI/l, and serum lactic dehydrogenase >600 UI/l, total bilirubin >1.2 mg/dl and/or periferical blood smear with hemolysis. The mean maternal age was 28 +/- 8 years; parity 2.7 +/- 2.3; gestational age 33 +/- 4 weeks. According to platelet count, 23 cases were identified to class 1, 29 to class 2 and the rest to Martin's class 3. There were 16 eclamptic patients. The platelet count was 67,604 +/- 31,535/mm3; alanine aminotransferase 271 +/- 297 UI/l; aspartate aminotransferase 209 +/- 178 UI/l; serum lactic dehydrogenase 1444 +/- 1295 UI/l; serum creatininine levels 1.1 +/- 0.8 mg/dl. Forty-one patients had diverse degree of renal function damage, renal dialysis and plasmapheresis was required in one female. Respiratory failure due to pulmonary edema was observed in four patients. All obstetric patients survived. There were four perinatal deaths. In our population sample, low rate of life-threatening maternal complications and low perinatal mortality were observed.

Complicaciones maternas y mortalidad perinatal en el síndrome HELLP. Registro multicéntrico en unidades de cuidados intensivos del área Buenos Aires. / [Maternal morbidity and perinatal mortality in HELLP syndrome. Multicentric studies in intensive care units in Buenos Aires area]

We analyzed the clinical characteristics, complications, severity, and maternal and fetal survival of patients suffering from HELLP syndrome (Hemolysis, Elevated Liver enzymes level, Low Platelet count) requiring admission to the intensive care unit in four hospitals from Buenos Aires area, Argentina. Data was revised in the charts from March 1997 to March 2003 and 62 patients were included in the study. During the second half of pregnancy or immediate puerperal period, diagnostic criteria were defined on the basis of preeclampsia and the following laboratory abnormalities: platelet count nadir <150,000/mm3, serum hepatic aminotransferases >70 UI/l, and serum lactic dehydrogenase >600 UI/l, total bilirubin >1.2 mg/dl and/or periferical blood smear with hemolysis. The mean maternal age was 28 +/- 8 years; parity 2.7 +/- 2.3; gestational age 33 +/- 4 weeks. According to platelet count, 23 cases were identified to class 1, 29 to class 2 and the rest to Martins class 3. There were 16 eclamptic patients. The platelet count was 67,604 +/- 31,535/mm3; alanine aminotransferase 271 +/- 297 UI/l; aspartate aminotransferase 209 +/- 178 UI/l; serum lactic dehydrogenase 1444 +/- 1295 UI/l; serum creatininine levels 1.1 +/- 0.8 mg/dl. Forty-one patients had diverse degree of renal function damage, renal dialysis and plasmapheresis was required in one female. Respiratory failure due to pulmonary edema was observed in four patients. All obstetric patients survived. There were four perinatal deaths. In our population sample, low rate of life-threatening maternal complications and low perinatal mortality were observed.

Sindrome platipnea-ortodeoxia por foramen oval permeable, aneurisma del septum interauricular y paralisis del hemidiafragma derecho. / [Platypnea-orthodeoxia syndrome, atrial septal aneurysm and right hemidiaphragmatic elevation with a right-to-left shunt through a patent foramen ovale]

Platypnea-orthodeoxia is an uncommon syndrome of dyspnea and hypoxemia induced by upright position, which is subsequently relieved by recumbency. The case reported involved a 75-year-old man with a seven days history of dyspnea in the upright position. The chest radiograph and CT scan demonstrated an elevated right hemidiaphragm. A surface echocardiogram with saline solution showed a patent foramen ovale (PFO) and atrial septal aneurysm. A pulmonary arteriogram was performed showing no evidence of pulmonary embolism and normal pulmonary arterial pressures. Later, he also developed dyspnea in the supine position and a transesophageal echocardiogram with contrast demonstrated a large right to left shunt through a PFO. The closure by a catheter-deployed double-umbrella device caused an immediate improvement in the patients oxygenation.

Sindrome platipnea-ortodeoxia. / [Platypnea-orthodeoxia syndrome]

Platypnea-orthodeoxia is an uncommon syndrome of dyspnea and hypoxemia induced by upright posture, which is subsequently relieved by recumbency. Traditionally, this condition has been reported in association with pulmonary, hepatic and cardiac diseases, but the mechanism is different in each situation. In presence of an atrial septal defect, a right to left cardiac shunt resulting as a consequence of redirection of the inferior vena cava flow towards the atrial septum and results in postural hypoxemia. In pulmonary shunts, as in hepatopulmonary syndrome and a-v pulmonary fistulas, the mechanism of hypoxemia is related to the preferential circulation to basal areas of both lungs in the upright position. On the other hand, lung diseases affecting basal areas and increasing the alveolar pressure are related to the development of parenchimal pulmonary shunts with hypoxemia during postural changes, since the dead space, the functional shunt and the hypoxic vascular pulmonary constriction are affected. The autonomic neuropathy may attenuate normal sympathetic vasoconstrictor responses during postural changes, resulting in ventilation-perfusion mismatching and hypoxemia. Clinical and therapeutic aspects of this sindrome are provided.

[Polymyositis with ventilatory incapacity and respiratory insufficiency]. / Polimositis con incapacidad ventilatoria e insuficiencia respiratoria.

The inflammatory diseases of muscle are a group of disorders characterized by proximal muscle weakness. Most cases fall into three major diagnostic categories, polymyositis (PM), dermatomyositis and inclusion body myositis. Respiratory complications are a common feature and are an important cause of morbidity and mortality. The three main types of pulmonary involvement are interstitial lung disease, aspiration pneumonia and ventilatory incapacity (VI) due to muscle weakness. There are few reported cases in which mechanical ventilation has been used in patients with PM and VI in absence of lung disease. We present a patient with PM and VI due to muscle weakness who underwent therapy maintenance with mechanical ventilator and was weaned 4 months later.

Polimositis con incapacidad ventilatoria e insuficiencia respiratoria. / [Polymyositis with ventilatory incapacity and respiratory insufficiency]

The inflammatory diseases of muscle are a group of disorders characterized by proximal muscle weakness. Most cases fall into three major diagnostic categories, polymyositis (PM), dermatomyositis and inclusion body myositis. Respiratory complications are a common feature and are an important cause of morbidity and mortality. The three main types of pulmonary involvement are interstitial lung disease, aspiration pneumonia and ventilatory incapacity (VI) due to muscle weakness. There are few reported cases in which mechanical ventilation has been used in patients with PM and VI in absence of lung disease. We present a patient with PM and VI due to muscle weakness who underwent therapy maintenance with mechanical ventilator and was weaned 4 months later.

[Acute cardiovascular beriberi (shoshin-beriberi)]. / Beriberi cardiovascular agudo (shoshin-beriberi).

Beriberi (BB), thiamine deficiency, has been described in the Asian literature in the 17th century and is characterized by peripheral neuropathy and muscle weakness, also called "dry" beriberi (BB) to differentiate it from "wet" BB, with essentially cardiovascular manifestations. Wet can be either "classic" wet BB in which signs and symptoms of right-sided heart failure with normal or high cardiac output are the presenting features or the "shoshin" BB variant with severe biventricular failure and metabolic acidosis, which must be treated early to prevent the rapid development of low cardiac output failure and sudden death. In this case, we report a 58 year old alcoholic woman who developed dyspnea, oliguria, edema, cardiac failure with high output, metabolic acidosis, renal tubular dysfunction and serum lactate level of 5.6 mEq/L. Neurological examination revealed peripheral neuropathy in the lower legs and cognitive alteration. She was treated with a loading dose of 100 mg of intravenous thyamine and responded with a marked increase in urine output, correction of acidosis, reduction in pulmonary-capillary wedge pressure and a change of the hemodynamic pattern. We conclude that shoshin-BB is uncommonly encountered but not widely recognized. In lactic acidosis and/or hyperdynamic circulation without any other apparent etiology in patients with possible vitamin B1 deficiency, the diagnosis of BB must be considered and thiamine should be administered.

Beriberi cardiovascular agudo (shoshin-beriberi) / Acute cardiovascular beriberi (shoshin-beriberi)

Beriberi (BB), thiamine deficiency, has been described in the Asian literature in the 17th century and is characterized by peripheral neuropathy and muscle weakness, also called "dry" beriberi (BB) to differentiate it from "wet" BB, with essentially cardiovascular manifestations. Wet can be either "classic" wet BB in which signs and symptoms of right-sided heart failure with normal or high cardiac output are the presenting features or the "shoshin" BB variant with severe biventricular failure and metabolic acidosis, which must be treated early to prevent the rapid development of low cardiac output failure and sudden death. In this case, we report a 58 year old alcoholic woman who developed dyspnea, oliguria, edema, cardiac failure with high output, metabolic acidosis, renal tubular dysfunction and serum lactate level of 5.6 mEq/L. Neurological examination revealed peripheral neuropathy in the lower legs and cognitive alteration. She was treated with a loading dose of 100 mg of intravenous thyamine and responded with a marked increase in urine output, correction of acidosis, reduction in pulmonary-capillary wedge pressure and a change of the hemodynamic pattern. We conclude that shoshin-BB is uncommonly encountered but not widely recognized. In lactic acidosis and/or hyperdynamic circulation without any other apparent etiology in patients with possible vitamin B1 deficiency, the diagnosis of BB must be considered and thiamine should be administered