Paragangliomas carotídeos: hacia un tratamiento personalizado que reduzca la morbilidad / Carotid body tumours: Towards a personalised treatment that reduces morbidity

Los paragangliomas carotídeos (PGC) son tumores infrecuentes que muy raramente son causa de muerte. El conocimiento de las bases genéticas de los tumores de origen hereditario, más de un tercio del total, ha permitido identificar a la población en riesgo y establecer en ella medidas para un diagnóstico precoz de los tumores. El tratamiento más habitual ha sido el quirúrgico que, en no pocos casos, origina una importante morbilidad. Un amplio contingente de los PGC no experimenta crecimiento alguno, lo que justifica una conducta expectante. Aquellos tumores con crecimiento significativo deben ser tratados. La radioterapia ofrece unas cifras similares de control a las de la cirugía y no presenta secuelas neurológicas ni vasculares. No obstante, la cirugía está indicada en PGC Shamblin I/II de pacientes jóvenes, en los raros tumores malignos o hiperfuncionantes y en el fracaso de la radioterapia. Los tumores múltiples familiares deben tratarse conservadoramente (AU)

Carotid body paragangliomas (CBP) are uncommon tumours that very rarely cause death. The genetic basis of tumours of hereditary origin (more than a third of the total) has been determined in the last few years, which has helped to identify the population at risk and to implement screening methods for an early diagnosis of tumours. The most common treatment of CBP has been surgery, which frequently causes significant morbidity. A significant number of paragangliomas do not experience any growth, which justifies a wait-and-see approach using annual image studies. Those tumours with significant growth must be treated. Radiotherapy has similar outcomes to surgery and has no neurological or vascular sequelae. However, surgery is indicated in Shamblin I/II carotid body tumours in young patients, in the rare malignant or hyper-functioning tumours, and in the failure of radiotherapy. Multiple tumours of familial origin should be treated conservatively (AU)

Clinical ultrasound in the ICU: changing a medical paradigm. / Ecografía clínica en la unidad de cuidados intensivos: cambiando un paradigma médico.

In recent decades there has been an evolution from the traditional paradigm of sporadic ultrasound performed by radiologists and cardiologists in the ICU to clinical ultrasound performed by intensivists as an extension of patient evaluation rather than as a complementary test. Such clinical ultrasound aims to diagnose and treat the patient directly. All ultrasound modalities could be interesting in the ICU, either helping in decision making or guiding procedures. Clinical ultrasound training should include all the possibilities of ultrasound, and the tutelage of other trained intensivists and other specialists with more experience should be available at all times. Training should be phased into basic, advanced and expert levels, with adjustment to the contents of the CoBaTrICE Project and the recommendations of the SEMICYUC.

Toolkit para la creación de unidades de úlcera de pie diabético / A toolkit to create diabetic foot ulcer units

Bajo el nombre de «Toolkit para unidades de úlcera de pie diabético» se han diseñado un conjunto de herramientas para facilitar la puesta en marcha, el funcionamiento y la evaluación de este tipo de unidades clínicas. El Toolkit ha sido realizado por 6 cirujanos vasculares y 2 metodólogos, y para su elaboración se han consultado las principales guías de práctica clínica en el manejo del pie diabético. El Toolkit incluye material destinado a atención primaria y otras especialidades fuera del ámbito de la cirugía vascular (conceptos básicos, algoritmos de manejo, recomendaciones de prevención primaria y criterios de derivación a cirugía vascular), y material para el propio servicio de cirugía vascular (recomendaciones sobre los recursos necesarios para montar una unidad de úlcera de pie diabético, algoritmos clínicos de manejo, cuadernos de recogida de datos, base de datos en Microsoft Access y herramientas de evaluación clínica y económica de la unidad) (AU)

Under the name of «The Diabetic Foot Ulcer Units Toolkit» we have designed a set of tools as an aid for the implementation, performance and evaluation of these Clinical Units. The Toolkit has been prepared by 6 vascular surgeons and 2 experts in methodology. Major clinical practice guidelines in the management of diabetic foot were consulted. The Toolkit includes tools for primary care and other specialties outside the field of vascular surgery (basic concepts, criteria for referral to DFUU, initial basic tests and recommendations for clinical management and primary prevention), and tools for vascular surgery service (list of optimal resources for the DFUU implementation, clinical management algorithms, data collection forms, Microsoft Access database, and tools for the clinical and economical evaluation) (AU)

Asymptomatic carotid stenosis in patients with intermittent claudication: epidemiological study.

AIM: The aim of this paper was to determine the prevalence of extracraneal carotid artery disease in patients with intermittent claudication, to describe classic cardiovascular risk factors in those with hemodynamically significant stenosis and to try to define subgroups at high risk, improving therefore the performance of non invasive testing. METHODS: A prospective descriptive study was conducted, with 146 patients reporting an intermittent claudication of the lower limbs and without a previous cerebrovascular event or carotid surgery. An ultrasonography examination was done. Risk factors were registed (smoking, dislipemia, arterial hypertension, diabetes mellitus), also ischemic cardiopathy and myocardial revascularization procedures. Univariate and multivariate analysis was made to define the variables associated with hemodynamically significant stenosis. RESULTS: Prevalence of hemodynamically significant stenosis was 23.2%. Smoking, dislipemia, arterial hypertension and diabetes mellitus were not significantly associated with carotid stenosis; 24.2% of patients affected of ischemic cardiopathy present a severe stenosis, and myocardial revascularization was a risk factor for carotid stenosis. CONCLUSION: Patients with claudication and ischemic miocardiopathy, especially when myocardial revascularization is needed, must be explored with carotid ultrasonography. In this patients, probably of hemodynamically significant carotid stenosis that requires treatment is more frequent.

Doppler transcraneal en el coma tras parada cardíaca / Transcranial Doppler ultrasound use in post-cardiac arrest coma

Introducción. El daño cerebral es la causa más común de morbilidad y mortalidad tras la reversión de una parada cardíaca. Objetivo. Revisar la utilidad de la ultrasonografía Doppler transcraneal (DTC) en la monitorización y en la valoración pronóstica de los pacientes en coma tras la recuperación inicial de una parada cardíaca. Desarrollo. El DTC registra la velocidad y la pulsatilidad del flujo sanguíneo cerebral, permitiendo realizar análisis hemodinámicos ‘latido a latido’, teniendo el valor añadido de no verse interferido en sus registros por la utilización de sedantes o por tratamientos como la hipotermia terapéutica moderada. En los pacientes que permanecen comatosos a las dos horas de haber sido recuperados de una parada cardíaca, la persistencia en las arterias cerebrales de un patrón DTC difusamente hipodinámico (baja velocidad media y alta pulsatilidad) pronostica mala recuperación neurológica. La presencia, precoz o tardía, de un patrón DTC hiperdinámico (alta velocidad media y baja pulsatilidad) se asocia también a mal pronóstico por evolución a hipertensión intracraneal y muerte encefálica. La coincidencia de arterias con patrones DTC hipodinámicos, con otras arterias normales o hiperdinámicas, sugiere focos de hipoperfusión que pueden ser predictores de ictus. Conclusiones. En los pacientes comatosos tras la recuperación inicial de una parada cardíaca, la utilización de exámenes DTC seriados permite detectar y tratar precozmente las alteraciones en la hemodinámica cerebral, disminuyendo la probabilidad de daño neurológico secundario. El DTC identifica en las primeras 24 horas a los pacientes que han evolucionado hacia un daño neurológico irreversible, evitando así la futilidad terapéutica (AU)

Introduction. Brain damage is the most common cause of morbidity and mortality after initial recovery of a cardiac arrest. Aim. To review the usefulness of transcranial Doppler ultrasonography (TCD) in monitoring and prognosis of comatose patients after initial recovery from cardiac arrest. Development. The TCD records the velocity and pulsatility of cerebral blood flow, allowing ‘beat to beat’ hemodynamic analysis, with the added value of not being interfered by the use of sedatives or therapeutic treatments such as moderate hypothermia. In patients who remain comatose two hours after being recovered from cardiac arrest, persistence in the cerebral arteries of a diffuse hypodynamic TCD pattern (low medium velocity and high pulsatility) also predicts poor neurologic recovery. Early or late presence of a diffuse hyperdynamic TCD pattern (high medium velocity and low pulsatility) is also associated with poor prognosis because progression to intracranial hypertension and brain death. Coincidence of hypodynamic arteries and other with normal or hyperdynamic TCD patterns, suggests foci of hypoperfusion that may be predictors of stroke. Conclusions. Using serial TCD examinations in comatose patients after initial recovery from cardiac arrest, to detect and treat early changes in cerebral hemodynamics, will decrease the likelihood of secondary neurological damage. In the first 24 hours, TCD could identify patients who have progressed to irreversible neurological damage, thus avoiding therapeutic futility (AU)

Utilidad del Doppler transcraneal en la resucitación de la parada cardíaca / Transcranial Doppler ultrasonography usefulness in cardiac arrest resuscitation

Durante la resucitación cardiopulmonar y tras la recuperación de la circulación espontánea, una perfusión tisular efectiva determina el pronóstico final. La ultranosografía Doppler transcraneal (DTC) registra la velocidad y la pulsatilidad del flujo sanguíneo cerebral y permite realizar análisis hemodinámicos «latido a latido». Durante la resucitación cardiopulmonar la velocidad sistólica máxima alcanzada refleja la perfusión cerebral en cada compresión torácica. Tras la recuperación de la circulación espontánea, la persistencia después de 2h de un patrón arterial cerebral hipodinámico (baja velocidad media y alta pulsatilidad en la DTC) pronostica mala recuperación neurológica. La presencia, precoz o tardía, de un patrón de DTC hiperémico (alta velocidad media y baja pulsatilidad) se asocia a mal pronóstico por evolución a hipertensión intracraneal; su aparición durante la fase de recalentamiento debería llevar a reinstaurar la hipotermia terapéutica La coincidencia de arterias con patrones hipodinámicos con otras normales o hiperdinámicas indica focos de hipoperfusión que son predictores de ictus (AU)

An effective tissue perfusion has decisive influence on the final prognosis both during cardiopulmonary resuscitation (CPR) and after recovery of spontaneous circulation (ROSC). The transcranial Doppler ultranosography (TCD) examines the velocity and pulsatility of cerebral blood flow, making it possible to perform "beat to beat" hemodynamic analysis. During CPR, TCD peak systolic velocity reflects cerebral perfusion of the chest compressions. Beyond 2 hours after ROSC, persistence in the cerebral arteries of a hemodynamic TCD pattern (low velocities with high pulsatilities) predicts poor neurological prognosis. Early or delayed presence of a hyperemic TCD pattern (high velocities with low pulsatilities) is associated conclusively with evolution to intracranial hypertension and its appearance during the rewarming process should lead to immediate return to therapeutic hypothermia. The coincidence of hypodynamic cerebral arteries and others with normal or hyperemic TCD patterns may indicate the presence of focal hypoperfusion that could predict stroke after ROSC (AU)

[Transcranial Doppler ultrasonography usefulness in cardiac arrest resuscitation]. / Utilidad del Doppler transcraneal en la resucitación de la parada cardíaca.

An effective tissue perfusion has decisive influence on the final prognosis both during cardiopulmonary resuscitation (CPR) and after recovery of spontaneous circulation (ROSC). The transcranial Doppler ultranosography (TCD) examines the velocity and pulsatility of cerebral blood flow, making it possible to perform "beat to beat" hemodynamic analysis. During CPR, TCD peak systolic velocity reflects cerebral perfusion of the chest compressions. Beyond 2 hours after ROSC, persistence in the cerebral arteries of a hemodynamic TCD pattern (low velocities with high pulsatilities) predicts poor neurological prognosis. Early or delayed presence of a hyperemic TCD pattern (high velocities with low pulsatilities) is associated conclusively with evolution to intracranial hypertension and its appearance during the rewarming process should lead to immediate return to therapeutic hypothermia. The coincidence of hypodynamic cerebral arteries and others with normal or hyperemic TCD patterns may indicate the presence of focal hypoperfusion that could predict stroke after ROSC.

[Managing the post-cardiac arrest syndrome. Directing Committee of the National Cardiopulmonary Resuscitation Plan (PNRCP) of the Spanish Society for Intensive Medicine, Critical Care and Coronary Units (SEMICYUC)]. / Manejo del síndrome posparada cardíaca. Comité Directivo del Plan Nacional de Resuscitación Cardiopulmonary de la SEMICYUC (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias).

Since the advent of cardiopulmonary resuscitation more than 40 years ago, we have achieved a return to spontaneous circulation in a growing proportion of patients with cardiac arrest. Nevertheless, most of these patients die in the first few days after admission to the intensive care unit (ICU), and this situation has not improved over the years. Mortality in these patients is mainly associated to brain damage. Perhaps recognizing that cardiopulmonary resuscitation does not end with the return of spontaneous circulation but rather with the return of normal brain function and total stabilization of the patient would help improve the therapeutic management of these patients in the ICU. In this sense, the term cardiocerebral resuscitation proposed by some authors might be more appropriate. The International Liaison Committee on Resuscitation recently published a consensus document on the "Post-Cardiac Arrest Syndrome" and diverse authors have proposed that post-arrest care be integrated as the fifth link in the survival chain, after early warning, early cardiopulmonary resuscitation by witnesses, early defibrillation, and early advanced life support. The therapeutic management of patients that recover spontaneous circulation after cardiopulmonary resuscitation maneuvers based on life support measures and a series of improvised actions based on "clinical judgment" might not be the best way to treat patients with post-cardiac arrest syndrome. Recent studies indicate that using goal-guided protocols to manage these patients including therapeutic measures of proven efficacy, such as inducing mild therapeutic hypothermia and early revascularization, when indicated, can improve the prognosis considerably in these patients. Given that there is no current protocol based on universally accepted evidence, the Steering Committee of the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive Medicine and Cardiac Units has elaborated this document after a thorough review of the literature and an online discussion involving all the members of the committee and a consensus meeting with the aim of providing a platform for the development of local protocols in different ICSs in our country to fit their own means and characteristics.

[Contribution of the patent foramen ovale to the etiopathogeny of the irritable bowel syndrome]. / Contribución del foramen oval permeable a la etiopatogenia del síndrome de intestino irritable.

A higher prevalence of cardiac right-to-left shunt through a patent foramen ovale (PFO) has been recently reported in the irritable bowel syndrome (IBS). At the same time, signs of ischemia in medullary cerebral microcirculation and the presence of excess sympathetic activity in peripheral circulation have been identified, both related with change in pain perception and autonomic dysfunction characteristic of IBS. Considering these findings together, the possible etiopathogenic role of PFO in the development of IBS can be proposed, because the paradoxical embolism characteristic of PFO could damage the cerebral and intestinal microcirculation, and that injury would be also amplified by the percentage of venous blood that shunts the pulmonary filter, producing an alteration in the metabolism of serotonin, pro-inflammatory bradykinins or neurotensin, substances with a proven etiopathogenic relationship with IBS.

[Some uncommon applications of transcranial Doppler in the intensive care unit]. / Algunas aplicaciones del Doppler transcraneal no habituales en las unidades de cuidados intensivos.

We present the case of a 64-year old woman with shock related to ischemic colitis associated with paradoxical embolism through a foramen ovale. Some utilities of transcranial Doppler ultra-sonography applied in this case that could have an usual interest in intensive and intermediate care are discussed. These include analysis of the regional distribution of cerebral blood flow, intracranial arterial continuous monitoring for detection of spontaneous microembolisms and injection of microbubbles to detect right to left shunts. The added value of using power M-mode Doppler in transcranial Doppler evaluations is highlighted.