Consecuencias de la obesidad en los resultados de la cirugía cardiaca. Análisis del registro ARIAM / Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry

Fundamento y objetivo: La obesidad puede acompañarse de peores resultados tras cirugía cardiaca. Nuestro objetivo es evaluar las consecuencias de la obesidad en relación con la aparición de complicaciones postoperatorias, la estancia y la mortalidad. Método: Estudio observacional, prospectivo y multicéntrico de pacientes recogidos en el registro ARIAM de cirugía cardiaca de adultos entre marzo de 2008 y marzo de 2011. Se han analizado variables clínicas, del acto quirúrgico, complicaciones postoperatorias y mortalidad, comparando los grupos de pacientes con índice de masa corporal (IMC) mayor o menor de 30 kg/m2. Resultados: El estudio incluye 4.172 pacientes con una edad media (DE) de 64,03 (12,08) años, IMC de 28,53 (4,7) kg/m2 y EuroSCORE de 5,58 (2,91). En 1.490 pacientes (35,7%) el IMC fue mayor de 30 kg/m2. No se encontraron diferencias en el desarrollo de complicaciones posquirúrgicas globales (33% en obesos y 35,8% en no obesos, p = 0,07). Los pacientes obesos mostraron menor necesidad de reintervención quirúrgica y menor incidencia de accidente cerebrovascular en el postoperatorio (p < 0,05). Sin embargo, sí presentaron significativamente mayor deterioro de la función renal (p = 0,009). La estancia en la Unidad de Cuidados Intensivos (UCI) fue similar en ambos grupos, mientras que en planta fue mayor en los obesos, 9,04 (10,43) frente a 8,18 (9,2) días (p = 0,01). Tras ajustar por gravedad y tiempo de circulación extracorpórea, los obesos presentaron una mortalidad inferior, sin llegar a ser estadísticamente significativa (odds ratio 0,94, intervalo de confianza del 95% 0,79-1,04). Conclusiones: Los enfermos obesos sometidos a cirugía cardiaca presentan una mortalidad, complicaciones y estancia similares a las de los no obesos. Estos pacientes son reintervenidos con menos frecuencia, aunque es más habitual el desarrollo de fracaso renal agudo en el postoperatorio (AU)

Background and objective: Obesity is a disease that affects a large part of the population and has been associated with worse outcomes after cardiac surgery. The aim of our study is to evaluate the consequences of obesity related to postoperative complications, hospital length of stay and mortality. Methods: Observational, prospective, multicenter study of patients included in ARIAM registry of adult cardiac surgery between March 2008 to March 2011. We analyzed clinical variables, the surgical procedure, postoperative complications and mortality, comparing the group of patients with body mass index (BMI) greater or less than 30 kg/m2. Results: The study included 4,172 patients with a mean age of 64.03 (SD 12.08) years, BMI 28.53 (4.7) and EuroSCORE 5.58 (2.91). In 1,490 patients (35.7%) BMI was greater than 30. There were no differences in the development of overall postoperative complications (33% in obese and non-obese 35.8%,P = .07), although there were less appreciated reoperation rate or stroke (P < .05), as well as further development postoperative renal failure (P = .009). After adjusting for severity and length of cardio by pass time, obese patients had lower mortality without being statistically significant. OR 0.94 (0.79-1.04). There were no differences in ICU length of stay, but obese patients had greater Ward length of stay 9.04 (10.43) vs. 8.18 (9.2) days, P = .01. Conclusions: Obese patients undergoing cardiac surgery have a mortality, rate of complications and length of stay similar to non-obese. Obese patients required less reoperations but developed more frequently postoperative renal failure (AU)

[Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry]. / Consecuencias de la obesidad en los resultados de la cirugía cardiaca. Análisis del registro ARIAM.

BACKGROUND AND OBJETIVE: Obesity is a disease that affects a large part of the population and has been associated with worse outcomes after cardiac surgery. The aim of our study is to evaluate the consequences of obesity related to postoperative complications, hospital length of stay and mortality. METHODS: Observational, prospective, multicenter study of patients included in ARIAM registry of adult cardiac surgery between March 2008 to March 2011. We analyzed clinical variables, the surgical procedure, postoperative complications and mortality, comparing the group of patients with body mass index (BMI) greater or less than 30 kg/m(2). RESULTS: The study included 4,172 patients with a mean age of 64.03 (SD 12.08) years, BMI 28.53 (4.7) and EuroSCORE 5.58 (2.91). In 1,490 patients (35.7%) BMI was greater than 30. There were no differences in the development of overall postoperative complications (33% in obese and non-obese 35.8%, P=.07), although there were less appreciated reoperation rate or stroke (P<.05), as well as further development postoperative renal failure (P=.009). After adjusting for severity and length of cardio by pass time, obese patients had lower mortality without being statistically significant. OR 0.94 (0.79-1.04). There were no differences in ICU length of stay, but obese patients had greater Ward length of stay 9.04 (10.43) vs. 8.18 (9.2) days, P=.01. CONCLUSIONS: Obese patients undergoing cardiac surgery have a mortality, rate of complications and length of stay similar to non-obese. Obese patients required less reoperations but developed more frequently postoperative renal failure.

Intoxicación aguda grave por flecainida / Severe acute flecainide intoxication

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Indicaciones en ventilación mecánica no invasiva. ¿Evidencias en la bibliografía médica? / Indications of non-invasive mechanical ventilation: What's the literature evidence?

La introducción progresiva de la ventilación mecánica no invasiva (VMNI) en el tratamiento de la insuficiencia respiratoria ha permitido, por un lado, aumentar el número de indicaciones clínicas de esta técnica y, por otro, evitar o reducir las complicaciones derivadas de la ventilación mecánica convencional. Los resultados obtenidos son variables en virtud de las circunstancias y el tipo de enfermedad que motivan su aplicación. Con el propósito de revisar los estudios existentes acerca de su uso y establecer niveles de evidencia a su favor, las diferentes sociedades científicas han elaborado conferencias de consenso que establecen el grado de utilidad de la VMNI en sus múltiples indicaciones (AU)

The progressive introduction of non-invasive mechanical ventilation (NIMV) in the management of respiratory failure has increased the number of clinical indications and has reduced common complication of conventional mechanical ventilation. Results of the technique are variable depending on the disease that causes the respiratory failure. With the purpose of reviewing studies about the use of NIMV and to report levels of evidence, different scientific societies have elaborated consensus conferences to establish the utility of NIMV in different indications (AU)

[Indications of non-invasive mechanical ventilation: what's the literature evidence?]. / Indicaciones en ventilación mecánica no invasiva. ¿Evidencias en la bibliografía médica?

The progressive introduction of non-invasive mechanical ventilation (NIMV) in the management of respiratory failure has increased the number of clinical indications and has reduced common complication of conventional mechanical ventilation. Results of the technique are variable depending on the disease that causes the respiratory failure. With the purpose of reviewing studies about the use of NIMV and to report levels of evidence, different scientific societies have elaborated consensus conferences to establish the utility of NIMV in different indications.

Uso compasivo de factor VII a recombinante en pacientes con hemorragia grave / Compasive use or rFVIIa in critical patients with severe bleeding

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Intoxicación mortal por metanol: donante de órganos / Patient with fatal methanol intoxication: organ donor

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Replacement of 24-h creatinine clearance by 2-h creatinine clearance in intensive care unit patients: a single-center study.

OBJECTIVE: To estimate the usefulness of 2-h creatinine clearance (CrCl) in the ICU and define variables that may reduce agreement. DESIGN: Prospective study. SETTING: Polyvalent ICU of a university hospital. PATIENTS: 359 patients. INTERVENTIONS: We compared 24-h CrCl (CrCl-24h), as the standard measure, with 2-h CrCl (CrCl-2h) (at the start of the period) and the Cockroft-Gault equation (Ck-G). MEASUREMENTS AND RESULTS: The 2-h sample was lost in two patients (0.6%) and the 24-h sample was lost in 50 patients (13.9%). The mean Ck-G was 87.4+/-3.05, with CrCl-2h 109.2+/-4.46 and CrCl-24h 100.9+/-4.21 ml/min/1.73 m2 (r2 of 0.88 for CrCl-2h and 0.84 for Ck-G). The differences from ClCr-24h were 21.8+/-3.3 (p<0.001) for the Ck-G and 8.3+/-2.6 (p<0.05) for CrCl-2h (p<0.05). In the subgroup of patients with CrCl-24h<100 ml/min/1.73 m2, the CrCl-24h value was 52.9+/-2.71 vs. 51.6+/-2.14 for CrCl-2h (p=ns) and 57.6+/-2.56 (p<0.001) for the Ck-G. Patients with CrCl<100 ml/min only showed variability in hyperglycemia during the 24-h period. CONCLUSIONS: In intensive care patients, 24-h CrCl results in a large proportion of non-valid determinations, even under conditions of close monitoring. Two-hour CrCl is an adequate substitute, even in patients who are unstable or who have irregular diuresis where a 24-h collection is impossible. The Cockroft-Gault equation seems less useful in this setting.

Early hemodynamic improvement is a prognostic marker in patients treated with continuous CVVHDF for acute renal failure.

We examined whether hemodynamic improvement after high-flow hemofiltration predicts survival in patients treated with standard continuous renal replacement therapy (CRRT). This was a prospective, observational cohort study of 169 patients, measuring the mean arterial pressure (MAP) and norepinephrine (NE) dosage before and 24 hours after CRRT. Responders were defined as having a 20% reduction in NE dosage or a 20% rise in MAP with no increase in NE, compared with nonresponders. Patients were considered to be unstable if they were receiving NE or their MAP was lower than 60 mm Hg before CRRT. Of the 169 patients, 68% were men; mean age was 53.8 years (52.7 to 54.9), with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II at admission of 21.8 (21.2 to 22.3), of whom 114 were unstable at the start of CRRT. Overall mortality rate 15 days after the end of CRRT was 54.3% (57.7% in stable vs. 52.9% in unstable patients, p = NS). There were 99 responders and 70 nonresponders, the only differences being NE dosage (higher in responders, p < 0.01) and mortality rate (responders 30% vs. nonresponders 74.7%, p < 0.001). In unstable patients, mortality rate was 30% in responders versus 87% in nonresponders (p < 0.001) (72% sensitivity and 86% specificity for predicting death). Logistic regression analysis showed that the only variables associated with death were APACHE II at admission (OR, 1.06; 95% CI, 1.0 to 1.12), percent creatinine decrease (OR, 0.98; CI, 0.96 to 1.0), and lack of hemodynamic response to CRRT (OR, 7.04; CI, 3.3 to 15.02). Hemodynamic improvement after 24-hour CRRT is a strong predictor of survival.