[Von Willebrand factor, endothelial lesion, and ischemic heart disease]. / Factor de von Willebrand, lesión endotelial y cardiopatía isquémica.

OBJECTIVE: To analyze if the levels of von Willebrand factor (FvW) are higher in patients with ischemic heart disease than in healthy subjects and evaluate the relationship of these levels with clinical recurrence and coronary interventionism. DESIGN: Observational prospective study. PATIENTS: We analyzed the levels of FvW in 75 patients with ischemic heart disease who underwent coronary interventionism (Group I) and compared them with those of 30 healthy subjects with no cardiovascular risk factors and who, theoretically, had no coronary injuries (Group II). MAIN VARIABLES: Levels of FvW before coronary interventionism (sample 0), 24 hours after (sample 1), and at three months of out-patient follow-up (sample 2). A single measurement was made of the FvW levels in Group II. RESULTS: Subjects with ischemic heart disease had higher levels of FvW than healthy subjects (162+/-74% versus 95+/-33%; p=0.0001). FvW levels were significantly increased after coronary interventionism (162.4+/-74.9% in sample 0 versus 213+/-90% in sample 1; p=0.0001). Patients with clinical symptoms at three months have no significant difference regarding those with no symptoms in the FvW levels (125+/-63% versus 133+/-60%; p=0.57). CONCLUSIONS: FvW levels reflect an endothelial alteration in patients with ischemic heart disease. The increase of the levels after coronary interventionism could be due to the endothelial aggression itself of the intervention. It was not possible to demonstrate higher levels of FvW in patients with symptoms in the three month follow-up.

Factor de von Willebrand, lesión endotelial y cardiopatía isquémica / Von Willebrand factor, endothelial lesion, and ischemic heart disease

Objetivo. Analizar si los niveles de factor de von Willebrand (FvW) son más elevados en pacientes con cardiopatía isquémica que en individuos sanos, y evaluar la relación de dichos niveles con la recidiva clínica de angina y el intervencionismo coronario. Diseño. Estudio prospectivo observacional. Pacientes. Analizamos los niveles de FvW en 75 pacientes con cardiopatía isquémica sometidos a intervencionismo coronario (Grupo I), y los comparamos con los de 30 individuos sanos, sin factores de riesgo cardiovascular, y libres teóricamente de lesiones coronarias (Grupo II). Variables principales. Niveles de FvW antes de la realización del intervencionismo coronario (toma 0), a las 24 horas (toma 1) y a los tres meses durante el seguimiento ambulatorio (toma 2). En el Grupo II se efectuó una única determinación de los niveles de FvW. Resultados. Los sujetos con cardiopatía isquémica tuvieron unos niveles más elevados de FvW que los sujetos sanos (162 ± 74% frente a 95 ± 33%; p = 0,0001). Los niveles de FvW aumentaron de manera significativa tras el intervencionismo coronario (162,4 ± 74,9% en la toma 0 frente a 213 ± 90% en la toma 1; p = 0,0001). Los pacientes sintomáticos a los tres meses no presentaron diferencias significativas respecto a los asintomáticos en los niveles de FvW (125 ± 63% frente a 133 ± 60%; p = 0,57). Conclusiones. Los niveles de FvW reflejan una alteración endotelial en pacientes con cardiopatía isquémica. El aumento de los niveles tras el intervencionismo coronario podría ser debido a la propia agresión endotelial del intervencionismo. No se demuestran mayores niveles de FvW en pacientes sintomáticos en el seguimiento a tres meses

Objective. To analyze if the levels of von Willebrand factor (FvW) are higher in patients with ischemic heart disease than in healthy subjects and evaluate the relationship of these levels with clinical recurrence and coronary interventionism. Design. Observational prospective study. Patients. We analyzed the levels of FvW in 75 patients with ischemic heart disease who underwent coronary interventionism (Group I) and compared them with those of 30 healthy subjects with no cardiovascular risk factors and who, theoretically, had no coronary injuries (Group II). Main variables. Levels of FvW before coronary interventionism (sample 0), 24 hours after (sample 1), and at three months of out-patient follow-up (sample 2). A single measurement was made of the FvW levels in Group II. Results. Subjects with ischemic heart disease had higher levels of FvW than healthy subjects (162 ± 74% versus 95 ± 33%; p = 0.0001). FvW levels were significantly increased after coronary interventionism (162.4 ± 74.9% in sample 0 versus 213 ± 90% in sample 1; p = 0.0001). Patients with clinical symptoms at three months have no significant difference regarding those with no symptoms in the FvW levels (125 ± 63% versus 133 ± 60%; p = 0.57). Conclusions. FvW levels reflect an endothelial alteration in patients with ischemic heart disease. The increase of the levels after coronary interventionism could be due to the endothelial aggression itself of the intervention. It was not possible to demonstrate higher levels of FvW in patients with symptoms in the three month follow-up

[Predictors of outcome in blunt chest trauma]. / Marcadores pronósticos en los pacientes con traumatismo torácico cerrado.

INTRODUCTION: Thoracic trauma is often associated with polytrauma. Because mortality is high, the search for prognostic tools is useful. PATIENTS AND METHODS: A total of 108 patients with blunt thoracic trauma, 73 of whom had multiple injuries, were studied in an intensive care unit (ICU). The variables named as potential predictors of outcome were the need for mechanical ventilation, duration of ventilation, and high positive end-expiratory pressure (PEEP); the presence of rib fractures, pulmonary contusion, pleural involvement (hemo- and/or pneumothorax), or lung infection; the need for emergency surgery; mean duration of ICU stay, and age. We also studied whether or not the mortality rate was higher in polytrauma patients. Student t and chi2 tests (95% confidence level) and multiple regression analysis (Hosmer-Lemeshow goodness of fit) were used to analyze the results. RESULTS: The need for mechanical ventilation, radiographic evidence of pulmonary contusion, emergency surgery, and hemodynamic instability were risk factors for increased mortality. Higher risk of mortality was not demonstrated for patients with multiple injuries. For patients in need of mechanical ventilation, high PEEP was a predictor of poor prognosis. CONCLUSIONS: The presence of the aforementioned predictors (mechanical ventilation, high PEEP, pulmonary contusion, emergency surgery, and hemodynamic instability) indicate serious injury to the lung parenchyma, which is the main determinant of outcome for patients with thoracic trauma.

Marcadores pronósticos en los pacientes con traumatismo torácico cerrado / Predictors of outcome in blunt chest trauma

INTRODUCCIÓN: El traumatismo torácico suele producirse en el contexto de un politraumatismo. La mortalidad elevada de esta patología hace lógica la investigación de marcadores pronósticos. PACIENTES Y MÉTODOS: Estudio sobre 108 pacientes ingresados en una unidad de cuidados intensivos, con traumatismo torácico cerrado, de los cuales 73 fueron politraumatizados. Analizamos, como marcadores pronósticos, la necesidad de ventilación mecánica, su duración, la presión positiva máxima final de la espiración, las fracturas costales, la contusión pulmonar, las alteraciones pleurales (hemo y/o neumotórax), la sobreinfección respiratoria, la inestabilidad hemodinámica, la necesidad de cirugía urgente, así como la estancia media y la edad. Estudiamos si fue mayor la mortalidad en los politraumatizados. Se emplearon como herramientas estadísticas las pruebas de la t de Student y de la 2 (intervalo mínimo de confianza del 95 por ciento), y se realizó un análisis de regresión logística (bondad de ajuste test de Hosmer-Lemeshow). RESULTADOS: La necesidad de ventilación mecánica, la presencia radiológica de contusión pulmonar, la cirugía urgente y la inestabilidad hemodinámica comportan mayor mortalidad. No se demuestra mayor mortalidad en los enfermos politraumatizados. En los pacientes con ventilación mecánica, la presión positiva máxima final de la espiración requerida es un indicador de mayor mortalidad. CONCLUSIONES: Los marcadores positivos indican una mayor lesión en el parénquima pulmonar, lesión que es el determinante principal de la evolución de los pacientes con traumatismo torácico (AU)

Traumatismo craneoencefálico: valor pronóstico de los marcadores de hipercoagulabilidad y fibrinólisis / Head trauma: prognostic value of hypercoagulability and fibrinolysis markers

Objetivo. Estudiar la activación hemostática en los enfermos con traumatismo craneoencefálico (TCE) y su relación con la gravedad y el pronóstico. Diseño. Estudio de cohortes prospectivo con un período de inclusión de 28 meses y seguimiento evolutivo a los 6 meses. Ámbito. Un Servicio de Medicina Intensiva de un Hospital Universitario. Pacientes y método. Pacientes con TCE único, con menos de 6 horas de evolución al ingreso y que no presentaran situaciones que interfirieran con la coagulación. Intervenciones. Realizamos dos extracciones sanguíneas de vena periférica (al ingreso y a las 24 horas). Determinamos fragmentos de trombina 1+2 (F1+2), complejo trombina-antitrombina (TAT) y D-dímeros. La gravedad del TCE fue medida mediante Glasgow Coma Score (GCS) y dividimos a los pacientes en dos grupos, TCE grave y moderado-leve. La evolución fue medida mediante Glasgow Outcome Score (GOS), obteniendo dos grupos, buena y mala evolución. Realizamos un análisis estadístico de los resultados mediante ANOVA de dos vías. Resultados. Se incluyeron 45 enfermos. Edad media 46,1; 31 varones. GCS 10,1; SAPS II 32,5. Veintiséis enfermos presentaron TCE leve-moderado y 19 TCE grave. Veintisiete tuvieron mala evolución y 18 buena evolución. Los marcadores fueron más elevados de forma significativa en el grupo de TCE severo frente al grupo TCE levemoderado y el grupo de peor evolución frente al grupo de buena evolución. Conclusiones. F1+2, TAT y D-dímeros están más elevados en pacientes con TCE más grave y peores resultados evolutivos a los 6 meses (AU)

[Haemostatic activation in head injury]. / Activación hemostática en el traumatismo creoencefálico.

A relationship between Central Nervous System and coagulation has been known since the work by Goodnight et al5. When an encephalic injury occurs tissue damage causes the release of thromboplastin-related products, mainly the Tissular Factor. This release produces an activation of the coagulation system specially through its extrinsic path. With this physiopathologic basis we attempt to improve the knowledge of this relation by performing a prospective study at the Intensive Care Unit of our Hospital. The study included 67 patients with cranioencephalic trauma alone, with an average Glasgow coma scale score of 10 and a control group consisting of 40 healthy subjects. Two peripheral vein blood extractions were performed, at admission and 24 hours later. Global coagulation parameters (prothrombin time, activated partial thromboplastin time, platelet count and fibrinogen), hypercoagulability markers (prothrombin fragments F1+2 and thrombin-antithrombin complex (TAT)) and thrombolisis markers (D-dimer) were determined. Our results show that early after head trauma an increase in fragments F1+2, TAT and Ddimer occur. After the first 24 hours a significant decrease in hypercoagulability markers levels is detected. Modification of the global coagulation parameters was also detected. In conclusion, early after a cranioencephalic trauma a simultaneous state of hypercoagulability and thrombolysis occur which may have the purpose of improving the hemostatic balance.

Activación hemostática en el traumatismo craneoencefálico / Haemostatic activation in head injury

Desde los estudios de Goodnight et al'., se conoce la relación entre el sistema nervioso central y el sistema de la coagulación sanguínea. Cuando se produce una lesión a nivel del encéfalo, la destrucción tisular produce la liberación de sustancias tromboplastínicas, principalmente Factor Tisular. Esta liberación produce una activación de la coagulación principalmente por la vía extrínseca. Ante esta base fisiopatológica nos planteamos avanzar en el estudio de esta relación, para lo cual realizamos un estudio prospectivo en el Servicio de Medicina Intensiva del Hospital Clínico Universitario "Lozano Blesa" de Zaragoza. El estudio esta formado por 67 pacientes con traumatismo craneoencefálico aislado, con un Glasgow medio de 10 puntos y un grupo control formado por 40 personas sanas. Realizamos dos extracciones de vena periférica, al ingreso y a las 24 horas de evolución. Determinamos parámetros globales de la coagulación (tiempo de protrombina, tiempo de tromboplastina parcial activado, recuento de plaquetas y fibrinógeno), marcadores de hipercoagulabilidad (fragmentos de la protrombina F1+2 y complejo trombina antitrombina) y marcadores de fibrinolisis (D-dímeros).Nuestros resultados muestran que de forma precoz se produce un aumento en los niveles de fragmentos F1+2, TAT y D-dímeros tras producirse un traumatismo craneoencefálico. Una vez transcurridas las primeras 24 horas de evolución hay un descenso significativo de los marcadores de hipercoagulabilidad. También hemos detectado una alteración en los parámetros globales de la coagulación. Así de forma precoz tras un traumatismo craneoencefálico se produce un estado simultáneo de hipercoagulabilidad y fibrinolisis, que quizá intente conseguir un equilibrio hemostático (AU)

Neumonía adquirida en la comunidad, síndrome de distrés respiratorio agudo y sepsis severa por Chlamydia pneumoniae / Community-acquired pneumonia, acute respiratory distress syndrome, and severe sepsis due to Chlamdia pneumoniae

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[Analysis of the reliability of 4 ventilators used in critically ill patients]. / Análisis de la fiabilidad de cuatro ventiladores empleados en pacientes críticos.

OBJECTIVES: Mechanical ventilators are often used in critically-ill patients with acute respiratory insufficiency. We aimed to assess the reliability of four commonly used ventilators. METHODS: This experimental study assessed four Bio-Tek VT-2 ventilators set for different levels of impedance and compliance in comparison with a tester. We gathered data on differences between the ventilators and the tester for volumes supplied and end-expiratory pressures. Statistical significance was determined using a Student-t test (95% confidence interval) and a coefficient of variation was calculated to study variation over time in parameters programmed. Error margins were calculated and applied for each ventilator. RESULTS: For situations in which compliance and impedance are similar to those of patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome, there were differences in tidal volumes measured by the ventilators monitors and those actually supplied at the end of the breathing circuits, although the differences are only slightly greater than the error margins. The coefficients of variation were not significant at any of the compliance and impedance levels studied. CONCLUSIONS: In situations of low compliance and/or high impedance, tidal volumes supplied by ventilators and volumes shown on the monitors are different, although the differences are small and hardly exceed the ventilators acceptable error margins. The coefficient of variation indicated that the parameters set remain highly stable over time.

Aparición de trombopenia severa y hemorragia cerebral. Probable relación causa-efecto en el curso clínico de una brucelosis / Appearance of severe thrombopenia and intracerebral hemorrhage. A probable relation cause-effect in clinic course of brucellosis

La brucelosis es una zoonosis causada por microorganismos del género Brucella, transmitidos al hombre por animales domésticos. Puede afectar a cualquier órgano o sistema, y por lo tanto cursar con un amplio espectro de manifestaciones clínicas. Las complicaciones hematológicas son variables y consisten en anemia, leucopenia o trombopenia: En más del 30 por ciento de los casos aparece una discreta plaquetopenia, pero la observación de trombocitopenia grave es un raro hallazgo. En caso de aparecer clínica hemorrágica la localización más frecuente es la púrpura cutáneo-mucosa, seguida por el sangrado digestivo y la epixtasis. Un varón de 23 años, con historia de contacto con ganado ovino y tabaquismo, diagnosticado serológicamente de brucelosis aguda, ingresó en nuestra Unidad de Cuidados Intensivos, debido ã la aparición de trombopenia severa, sangrado en diversas localizaciones y hemorragia cerebral. Aunque la endocarditis es la causa más frecuente de mortalidad en la brucelosis, las complicaciones hematológicas pueden ser severas (AU)

[Non-invasive methods for evaluating reperfusion in acute myocardial infarct: enzymes and MIBI-SPECT cardiac gammagraphy]. / Métodos no invasivos de valorar la reperfusión en el infarto agudo de miocardio: enzimas y gammagrafía cardíaca con MIBI-SPECT.

INTRODUCTION: Several studies point out the importance of what is called rescue angioplasty or fibrinolysis when thrombolysis has been ineffective in acute myocardial infarction. Therefore, it is necessary to make use of new non-invasive methods to asses reperfusion and to safely establish that such a treatment has not been effective. PATIENTS AND METHOD: We present a work which is based on the assessment of patients with acute myocardial infarction treated with or without fibrinolysis. After determining cardiac enzymatic profiles of creatine kinase and MB isoform (time course, peak, appearance rate constant time-activity: K1). With cardiac imaging gammagraphies 99mTc-isonitrile-single-photon emission computed tomography pre and post treatment after to calculating myocardium at risk, salvage and relationship. RESULTS: In patients treated with fibrinolysis, the salvage myocardium was higher (8.3% vs 3.0%; p < 0.05). Considering that an improvement in perfusion defect (salvaged myocardium/myocardium at risk) higher than 30% can be viewed as an effective reperfusion, we can see that the percentage in the group treated with fibrinolysis being 45.8%, and the percentage in the group under conventional treatment being just 6.7%. Patients with acute myocardial infarction treated with fibrinolysis show much shorter start of rise-peak time and pain-peak time, all this with very significant differences for the creatine kinase (p < 0.0001) as well as for the MB (p < 0.001). Patients with reperfusion show a rapid increase in activity enzymatic, as demonstrated by the pain-peak time variable and the appearance rate constant time-activity (K1), with very significant differences in the latter (p < 0.0001). In relation with gammagraphy, values of K1 higher or equal to 0.19 for the creatine kinase and 0.14 for the MB isoform, achieved a sensibility of 83% and 91%, and a specificity of 85% and 80% respectively, to asses reperfusion. CONCLUSION: We think that cardiac imaging gammagraphy with isonitriles as well as as determination of the appearance rate enzymatic constant time-activity, can be useful in monitoring treatment with fibrinolysis in infarction patients. New studies are needed to assess these same aspects, with a lesser number of enzymatic determinations.

[Cardiac radionuclide scanning with 99mTc-MIBI-SPECT in acute myocardial infarction]. / Gammagrafía cardiaca con 99mTc-MIBI-SPECT en el infarto agudo de miocardio.

Several studies point out the importance of what is called rescue angioplasty or fibrinolysis (FB) when thrombolysis has been ineffective in acute myocardial infaction (AMI). Therefore, it is necessary to make use of new methods to asses reperfusion and to safely establish that such a treatment has not been effective. We present a work which is based on the assessment of patients with acute coronary heart disease: AMI patients treated with FB (N = 48), without FB (N = 15), unstable angina (N = 9); after determining cardiac imaging gammagraphies 99mTc-isonitrile-single-photon emission computed tomography (MIBI-SPECT) pre and post treatment, to assess myocardium at risk (MR), salvage (MS) and the existence or not of gammagraphic reperfusion. Unstable angina patients show a myocardial perfusion that is similar to AMI patients. However, in the case of unstable angina, perfusion is practically of a 100% 48 hours later, having almost completely saved the myocardium at risk (MS/MR = 81.5% +/- 27.7%), and with a non-existent residual myocardium (3.2% +/- 5.8%). In AMI patients treated with FB the salvage myocardium was higher [8.3 vs 3.0; p < 0.05). Considering that an improvement in perfusion defect (MS/MR)] higher than 30% can be viewed as an effective reperfusion, we can see that all the patients with unstable angina show reperfusion, the percentage in the AMI group treated with FB being 45.8%, and the percentage in the AMI group under conventional treatment being just 6.7%. Gammagraphy with 99mTc-MIBI-SPECT at admission allowed assessing regional perfusion in AMI patients during the early stage of their evolution. With a second exploration we could determine the amount of salvage myocardium and the existence of secondary reperfusion to FB treatment.

[Study of electrocardiographic alterations during the acute phase of intracerebral hemorrhage and their prognostic implications]. / Estudio de las alteraciones electrocardiográficas durante la fase aguda de una hemorragia intraparenquimatosa y sus implicaciones pronósticas.

The electrocardiographic abnormalities occurring with acute central nervous system disease were known phenomenon. In this study, we have done a descriptive study of 100 patients with intracranial haemorrhage (ICH) compared with a control group and the changes associated a worse prognostic. We have observed that the incidence of abnormalities electrocardiographic were most frequent in the patients with ICH (p < 0.05). The incidence of abnormalities in the pattern electrocardiographic was the 70% and the incidence of arrhythmias was the 56%. We have also observed that the presence of Q wave, QTc > or = 0.44 sec and the atrial fibrillations means a worse prognostic. We conclude that the incidence of abnormalities electrocardiographic in the ICH is elevate an the presence of Q wave, QTc > or = 0.44 an the atrial fibrillations means a worse prognostic.

[Epidemiological study of nosocomial meningitis in neurological patients]. / Estudio epidemiólogico de la meningitis nosocomial en el enfermo neurológico.

We realized a retrospective study of all the patients who developed a nosocomial meningitis after to admitted to the Intensive Care Unit of our hospital, during the last five years. Nosocomial meningitis was found in 3.29% of the neurologic patients. The most frequent causes of the meningitis was the external ventricular drainage (14.8%), post-neurosurgical (0.8%) and head injury (0.0007%). The causative bacterias were stafilococo, S. pneumoniae, K. pneunomiae and P. aeruginosa. The mortality was of the 39.06%.

[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.

[Descriptive study of hemodialysis in the critical patient. Report of 198 cases]. / Estudio descriptivo de la hemodiálisis en el paciente crítico. A propósito de 198 casos.

In the last five year, 198 critic patients developed acute renal failure, requiring hemodialysis in the hospital. We realized a descriptive study and analyzed the factors that were statistically associated with higher mortality: a surgical etiology, clinic criteria for the inicial of hemodialysis, respiratory failure, hemodynamic inestability, hepatic insufficciency, disseminated intravascular coagulacion and oliguric or anuria. The sepsis and the cardiorrespiratory complications were the cause of mortality most important. The 14% of the surviving requiring continue in the programs of hemodyalisis.