[Hemodynamic monitoring in the critically patient. Recomendations of the Cardiological Intensive Care and CPR Working Group of the Spanish Society of Intensive Care and Coronary Units]. / Monitorización hemodinámica en el paciente crítico. Recomendaciones del Grupo de Trabajo de Cuidados Intensivos Cardiológicos y RCP de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias.

Hemodynamic monitoring offers valuable information on cardiovascular performance in the critically ill, and has become a fundamental tool in the diagnostic approach and in the therapy guidance of those patients presenting with tissue hypoperfusion. From introduction of the pulmonary artery catheter to the latest less invasive technologies, hemodynamic monitoring has been surrounded by many questions regarding its usefulness and its ultimate impact on patient prognosis. The Cardiological Intensive Care and CPR Working Group (GTCIC-RCP) of the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) has recently impulsed the development of an updating series in hemodynamic monitoring. Now, a final series of recommendations are presented in order to analyze essential issues in hemodynamics, with the purpose of becoming a useful tool for residents and critical care practitioners involved in the daily management of critically ill patients.

[Bronchoalveolar lavage for diagnosing pneumonia in mechanically ventilated patients]. / Lavado broncoalveolar para el diagnóstico de neumonía en enfermos en ventilación mecánica.

OBJECTIVE: To evaluate the diagnostic role of bronchoalveolar lavage (BAL) in mechanically ventilated patients with suspected pneumonia and to describe the clinical outcome in the different kinds of pneumonia in critically ill patients. DESIGN: Descriptive study. SETTING: A 17-bed medical and surgical intensive care unit. PATIENTS: Mechanically ventilated patients admitted to the ICU from November 2003 to March 2006 with suspected pneumonia who underwent bronchoscopy with BAL. INTERVENTIONS: BAL was performed by fiberoptic bronchoscopy with three aliquots of 50 ml sterile normal saline. Recovered BAL fluid was pro-cessed for microbiologic analysis. MAIN VARIABLES OF INTEREST: Age, APACHE II score within the first 24 hours of admission, time on mechanical ventilation, ICU length of stay, mortality, and isolated bacteria were analyzed. RESULTS: A total of 96 cases of suspected pneumonia with BAL were recruited, including 4 groups: community associated pneumonia (CAP), 12 cases, early-onset ventilator-associated pneumonia (VAP), 26 cases, late-onset ventilator-associated pneumonia, 43 cases, and immunocompromised patients, 15 cases. BAL was positive (> 10000 ufc/ml) in 40 (41.7%) patients (2, 16, 17 and 5 patients with CAP, early-onset VAP, late-onset VAP and immunocompromised, respectively). Mortality was 33.3%, 26.9%, 25.6% and 73.3% in CAP, early-onset VAP, late-onset VAP and immunocompromised patients respectively. CONCLUSIONS: The low incidence of positive BAL in the CAP group supports using BAL only for particularly severe, selected cases. Mortality was very high in the immunocompromised patients. In the light of our personal experience, BAL is most useful in the diagnosis of pneumonia in the group of patients with VAP.

Lavado broncoalveolar para el diagnóstico de neumonía en enfermos en ventilación mecánica / C-reactive protein as a marker of mortality in intensive care unit

Objetivo. Evaluar la utilidad diagnóstica del lavado broncoalveolar (LBA) en enfermos en ventilación mecánica con sospecha de neumonía y describir los resultados clínicos de los diferentes tipos de neumonía en enfermos críticos. Diseño. Estudio descriptivo. Ámbito. Unidad de cuidados intensivos (UCI) médico-quirúrgica de 17 camas. Pacientes. Enfermos ingresados en UCI desde noviembre de 2003 a marzo de 2006 con ventilación mecánica y sospecha clínica de neumonía a quienes se realizó LBA. Intervenciones. Se realizó LBA a través de tubo orotraqueal con 150 ml de suero salino fisiológico, repartidos en tres alícuotas de 50 ml; la muestra se procesó para estudio microbiológico. Principales variables de interés. Edad, APACHE II al ingreso, días en ventilación mecánica, estancia en UCI, mortalidad y agentes etiológicos aislados en el LBA. Resultados. Se incluyó a 96 pacientes a quienes se realizó LBA; se distinguieron 4 grupos: neumonía adquirida en la comunidad (NAC), 12 casos; neumonía asociada a ventilación mecánica (NAVM) precoz, 26 casos. NAVM tardía, 43 casos, y neumonía en enfermos inmunodeficientes, 15 casos. El LBA fue positivo (> 10.000 ufc/ml) en 40 (41,7%) pacientes (2 con NAC, 16 con NAVM precoz, 17 con NAVM tardía, 5 con neumonía e inmunodeficiencia). La mortalidad fue del 33,3, el 26,9, el 25,6 y el 73,3% en NAC, NAVM precoz, NAVM tardía e inmunodeficientes, respectivamente. Conclusiones. La escasa sensibilidad del LBA en la NAC corrobora la actitud de limitar su indicación sólo a casos seleccionados. En el grupo de enfermos inmunodeficientes la mortalidad fue muy elevada. El LBA, según nuestra limitada experiencia, tiene su mayor utilidad en el diagnóstico de NAVM

Objective. To evaluate the diagnostic role ofbronchoalveolar lavage (BAL) in mechanicallyventilated patients with suspected pneumoniaand to describe the clinical outcome in the differentkinds of pneumonia in critically ill patients.Design. Descriptive study.Setting. A 17-bed medical and surgical intensivecare unit.Patients. Mechanically ventilated patients admittedto the ICU from November 2003 to March2006 with suspected pneumonia who underwentbronchoscopy with BAL.Interventions. BAL was performed by fiberopticbronchoscopy with three aliquots of 50 ml sterilenormal saline. Recovered BAL fluid was processedfor microbiologic analysis.Main variables of interest. Age, APACHE IIscore within the first 24 hours of admission, timeon mechanical ventilation, ICU length of stay,mortality, and isolated bacteria were analyzed.Results. A total of 96 cases of suspected pneumoniawith BAL were recruited, including 4 groups: community associated pneumonia (CAP), 12 cases, early-onset ventilator-associated pneumonia (VAP), 26 cases, late-onset ventilator-associated pneumonia, 43 cases, and immunocompromised patients, 15 cases. BAL was positive (>10000 ufc/ml) in 40 (41.7%) patients (2, 16, 17 and5 patients with CAP, early-onset VAP, late-onset VAP and immunocompromised, respectively).Mortality was 33.3%, 26.9%, 25.6% and 73.3% inCAP, early-onset VAP, late-onset VAP and immunocompromised patients respectively.Conclusions. The low incidence of positive BALin the CAP group supports using BAL only for particularlysevere, selected cases. Mortality wasvery high in the immunocompromised patients. Inthe light of our personal experience, BAL is mostuseful in the diagnosis of pneumonia in the groupof patients with VAP

[Minimally invasive hemodynamic monitoring with esophageal echoDoppler]. / Monitorización hemodinámica mínimamente invasiva con eco-doppler esofágico.

Hemodynamic monitoring is a key element in the care of the critical patients, providing an unquestionable aid in the attendance to diagnosis and the choice of the adequate treatment. Minimally invasive devices have been emerging over the past few years as an effective alternative to classic monitoring tools. The esophageal echoDoppler is among these. It makes it possible to obtain continuous and minimally invasive monitoring of the cardiac output in addition to other useful parameters by measuring the blood flow rate and the diameter of the thoracic descending aorta, which provides a sufficiently extensive view of the hemodynamic state of the patient and facilitates early detection of the changes produced by a sudden clinical derangement. Although several studies have demonstrated the usefulness of the esophageal Doppler in the surgical scene, there is scarce and dispersed evidence in the literature on its benefits in critical patients. Nevertheless, its advantages make it an attractive element to take into account within the diagnostic arsenal in the intensive care. The purpose of the following article is to describe how it works, its degree of validation with other monitoring methods and the role of esophageal echoDoppler as a minimally invasive monitoring tool for measuring cardiac output in the daily clinical practice, contributing with our own experience in the critical patient.

Monitorización hemodinámica mínimamente invasiva con eco-doppler esofágico / Minimally invasive hemodynamic monitoring with esophageal echodoppler

La monitorización hemodinámica es un elemento clave en el cuidado de los pacientes críticos, proporcionando una ayuda incuestionable en la asistencia al diagnóstico y en la elección de un tratamiento adecuado. Los dispositivos mínimamente invasivos han ido emergiendo durante los últimos años como una alternativa eficaz frente a las herramientas clásicas de monitorización. Entre ellos el eco-doppler esofágico, que permite, mediante la medición de la velocidad del flujo sanguíneo y el diámetro de la aorta torácica descendente, una monitorización continua y mínimamente invasiva del gasto cardíaco, además de otros parámetros igualmente útiles, proporcionando una visión suficientemente amplia del estado hemodinámico del paciente y facilitando la detección precoz de los cambios producidos por un deterioro clínico brusco. Aunque varios estudios han demostrado la utilidad del doppler esofágico en el ámbito quirúrgico, existe una evidencia escasa y dispersa en la literatura sobre el beneficio de esta herramienta en los pacientes críticos. Sin embargo, sus ventajas lo convierten en un atractivo elemento a tener en consideración dentro del arsenal diagnóstico de cuidados intensivos. El propósito del siguiente artículo es describir el funcionamiento, el grado de validación con otros métodos de monitorización y el papel del eco-doppler esofágico en la práctica clínica como herramienta de monitorización mínimamente invasiva del gasto cardíaco, aportando nuestra experiencia en el paciente crítico

Hemodynamic monitoring is a key element in the care of the critical patients, providing an unquestionable aid in the attendance to diagnosis and the choice of the adequate treatment. Minimally invasive devices have been emerging over the past few years as an effective alternative to classic monitoring tools. The esophageal echoDoppler is among these. It makes it possible to obtain continuous and minimally invasive monitoring of the cardiac output in addition to other useful parameters by measuring the blood flow rate and the diameter of the thoracic descending aorta, which provides a sufficiently extensive view of the hemodynamic state of the patient and facilitates early detection of the changes produced by a sudden clinical derangement. Although several studies have demonstrated the usefulness of the esophageal Doppler in the surgical scene, there is scarce and dispersed evidence in the literature on its benefits in critical patients. Nevertheless, its advantages make it an attractive element to take into account within the diagnostic arsenal in the intensive care. The purpose of the following article is to describe how it works, its degree of validation with other monitoring methods and the role of esophageal echoDoppler as a minimally invasive monitoring tool for measuring cardiac output in the daily clinical practice, contributing with our own experience in the critical patient

Relación de parámetros bioquímicos de estrés con índices de masa ósea / Relationship between biochemical factors associated to stress and bone mass indexes. AEBM reference 2003 award

Objetivos. Pretendemos observar si algunos de los parámetros bioquímicos asociados al estrés (cortisol plasmático y metanefrinas urinarias), se relacionan directamente con la aparición de osteoporosis en mujeres postmenopaúsicas, y por lo tanto, con una disregulación inmune, objetivable por alteraciones en factores bioquímicos como las citoquinas osteoclastogénicas (IL-1 e IL-6). Material y Métodos. En una cohorte de 173 mujeres, medimos cortisol, IL-1, IL-6, fosfatasa ácida tartrato-resistente (FATR) y metanefrinas urinarias, así como su densidad mineral ósea (BMD), en columna lumbar (L2-L4) y en cuello de fémur. Resultados. Obtuvimos una relación estadísticamente significativa (p<0.05), para las siguientes asociaciones: BMD en columna lumbar (L2-L4) y en cuello de fémur, respecto a metanefrinas urinarias (p=0.0319 y p=0.0234, respectivamente); IL-1-cortisol (p=0.0198); FATR-cortisol (p=0.015) e IL-6-FATR (p=0.016). Conclusiones. Existe una relación directa entre BMD disminuida y una elevación en un parámetro de estrés (metanefrinas urinarias), así como entre IL-1 y FATR con respecto a cortisol plasmático (índice bioquímico de estrés) (AU)