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2.
Medicina (B Aires) ; 80(6): 599-605, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-33254103

RESUMO

Procalcitonin guidance stimulates a reduction in the duration of antibiotic treatment in critically ill patients with a presumed bacterial infection, but its role in infections caused by multidrug-resistant bacteria has not been sufficiently explored. In this retrospective observational study, we analyzed procalcitonin curves of 32 patients with culture-confirmed ventilation-associated pneumonia (VAP) and catheter-related bloodstream infections (CRBSI) occurred during the period 11/1/2016 to 7/1/2019. Sixteen infections were caused by multidrug-resistant bacteria (10 CRBSI and 6 VAP) and other 16 by sensitive bacteria (10 CRBSI and 6 VAP). CRBSI generated by multidrug-resistant bacteria elicited significantly higher procalcitonin levels than CRBSI infections caused by sensitive bacteria (39 ± 30 υg/l vs. 10.7 ± 11 υg/l, p = 0.02). Patients with VAP caused by sensitive and multidrug-resistant bacteria elicited similar procalcitonin levels. The time to a decrease in procalcitonin level to less than 80% of the peak value or less than 0.5 υg/l upon effective antibiotic treatment was 7.2 ± 2.9 days in multidrug-resistant bacteria vs. 5 ± 1.8 days in sensitive bacteria (p = 0.03). In multidrug-resistant bacteria, the inflammatory response measured by procalcitonin is stronger and longer, even with an effective antibiotic treatment. However, the decline occurs before the conventional antibiotic scheme is completed. The potential application of antibiotic protocols guided by procalcitonin to these groups of patients grants further studies aimed to reduce exposure to antibiotics in critical multidrug-resistant infections.

3.
Medicina (B Aires) ; 80(6): 710-713, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-33254121

RESUMO

Critical asthma syndrome is a life-threatening medical condition that can lead to irreversible hypoxia or cardiorespiratory arrest. Invasive mechanical ventilation is one of the therapeutic pillars, however, it can also develop ventilator-induced lung injury. For this reason, the use of extracorporeal membrane oxygenation (ECMO) could be an additional strategy to improve gas exchange and reduce damage induced by mechanical ventilation. We present the case of a patient with critical asthma syndrome who required ECMO due to severe barotrauma.

4.
Rev Fac Cien Med Univ Nac Cordoba ; 77(3): 187-190, 2020 08 21.
Artigo em Espanhol | MEDLINE | ID: mdl-32991106

RESUMO

Objetivo: Medición de la eficacia y relevamiento de las complicaciones asociadas a la a realización de traqueostomía percutánea (TP) guiada por videobroncoscopia en un hospital universitario de alta complejidad. Materiales y métodos: Estudio observacional retrospectivo realizado entre mayo de 2017 y agosto de 2019. El criterio para la indicación de TP fue desvinculación prolongada de la ventilación mecánica en todos los casos. Incluyó pacientes mayores de 18 años en que se realizó TP electiva guiada por videobroncoscopia. Se registraron variables demográficas, APACHE II y días de ventilación mecánica previos a la TP. La eficacia del procedimiento fue evaluada en base a la tasa de éxito en la ejecución, la necesidad de conversión a técnica abierta. Asimismo, se registraron las complicaciones observadas. Resultados: Se evaluaron 235 procedimientos (149 hombres y 86 mujeres) en pacientes con edad media de 61 años ± 19, un score APACHE II 18 ± 8. La TP pudo ser ejecutada en forma rápida y satisfactoria en todos los pacientes sin requerimiento de conversión a técnica abierta. Se presentaron complicaciones tempranas en el 3,8% (9) de los casos. El sangrado menor fue la complicación más frecuentemente observada en 5 casos (2,1%), hipotensión en 3 casos (1,3%) e hipoxemia transitoria en un caso (0,4%). Asimismo el 2,1% (5) de los casos registró complicaciones tardías. Conclusión: La realización de TP mediante la técnica de dilatador único guiada por videobroncoscopia se describe como un procedimiento efectivo y seguro, que puede realizarse en unidades de cuidados intensivos con baja tasa de complicaciones. Objective: Measurement of the efficacy and complications associated with performing percutaneous tracheostomy (PT) guided by video bronchoscopy. Materials and methods: Retrospective observational study conducted between May 2017 and August 2019. Adult patients who underwent elective PT guided by video bronchoscopy were included. The criteria for the indication of PT was prolonged weaning from mechanical ventilation in all cases. Demographic variables, APACHE II score and days of mechanical ventilation prior to PT were recorded. The efficacy of the procedure was evaluated based on the success rate in the execution, the need for conversion to open technique. Also complications observed were recorded. Results: 235 procedures (149 men and 86 women) were evaluated in patients with an average age of 61 years ± 19 and APACHE II score 18 ± 8. The PT was performed quickly and satisfactorily in all patients without conversion to open technique in any case. Complications occurred in 3.8% (9) of the cases. Minor bleeding was the most frequently observed complication in 5 cases (2.1%), hypotension in 3 cases (1.3%), and transient hypoxemia in one patient (0.4%). Also, 2,1% (5) of the cases presented late complications. Conclusion: Performing PT guided by video bronchoscopy is described as an effective and safe procedure that can be done in intensive care units with a low rate of complications.


Assuntos
Broncoscopia , Traqueostomia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
5.
Rev Fac Cien Med Univ Nac Cordoba ; 77(3): 208-210, 2020 08 21.
Artigo em Espanhol | MEDLINE | ID: mdl-32991115

RESUMO

Introduction: Idiopathic systemic capillary leak syndrome (ISCLS) or Clarkson's disease is unusual but potentially lethal, characterized by recurrent shock incidents and anasarca secondary to idiopathic increase of capillary permeability. In such a context, the use of venoarterial Extracorporeal Membrane Oxygenation (ECMO) as cardiorespiratory support is a rescue action that seeks hemodynamic stability generation until spontaneous disappearance of the capillary occurs with the objective of surpassing the complications of resorption phase. Case Report: A 42 year old patient presented ISCLS and required ECMO as hemodynamic support for 8 days. She remained 20 days in Intensive Care Unit and was given hospital release after 43 days. Conclusions: The use of ECMO in the reported case was a useful strategy in the ISCLS management as a bridge to recovery both in the leak stage and the fluid resorption phase. Notwithstanding its indication is limited to thoroughly selected patients and requires further debate between specialists about its risks and benefits.


Assuntos
Síndrome de Vazamento Capilar , Oxigenação por Membrana Extracorpórea , Adulto , Síndrome de Vazamento Capilar/terapia , Feminino , Humanos , Unidades de Terapia Intensiva
6.
Rev Fac Cien Med Univ Nac Cordoba ; 77(3): 214-217, 2020 08 21.
Artigo em Espanhol | MEDLINE | ID: mdl-32991116

RESUMO

Introduction: Electrical burns account for 3 to 4% of all burns. The most common sites of impact are the cardiovascular system, muscle tissue, neurological and skin. The commitment of the respiratory system is uncommon, with few cases reported in the literature. Case: 26-year-old male patient who enters after high-voltage electrical injury. He presented skin and respiratory distress engagement with requirement of mechanical respiratory assistance, deep sedation and neuromuscular blockade. Conclusion: There are few reported cases in the literature of lung injury associated with electrical trauma. Recognizing the respiratory system as a possible site of impact by highlighting the importance of advanced life support is critical.


Assuntos
Queimaduras por Corrente Elétrica , Lesão Pulmonar , Adulto , Queimaduras por Corrente Elétrica/complicações , Humanos , Lesão Pulmonar/etiologia , Masculino
7.
Medicina (B Aires) ; 80(4): 397-400, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32841146

RESUMO

Aspergillus tracheobronchitis is a rare form of invasive aspergillosis reported exceptionally in the immunocompetent patient. Its diagnosis is difficult, and the treatments proposed so far are of little effectiveness, all of which constitute a real problem for the health team. We present the case of an immunocompetent 28 years old woman, with no epidemiological background, who developed necrotizing tracheobronchitis due to invasive aspergillosis and received voriconazole with local instillation by bronchoscopy with a good response.


Assuntos
Aspergilose , Infecções Respiratórias , Adulto , Antifúngicos , Bronquite , Broncoscopia , Feminino , Humanos , Traqueíte
8.
Chest ; 2020 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-32805238

RESUMO

BACKGROUND: The prevalence of reverse triggering (RT) in the early phase of ARDS is unknown. RESEARCH QUESTION: During early ARDS, what is the proportion of patients affected by RT, what are its potential predictors, and what is its association with clinical outcomes? STUDY DESIGN AND METHODS: This was prospective, multicenter, and observational study. Patients who met the Berlin definition of ARDS with less than 72 h of mechanical ventilation and had not been paralyzed with neuromuscular blockers were screened. A 30-min recording of respiratory signals was obtained from the patients as soon as they were enrolled, and the number of breaths with RT were counted. RESULTS: One hundred patients were included. ARDS was mild to moderate in 92% of them. The recordings were obtained after a median of 1 day (interquartile range, 1-2 days) of ventilation. Fifty patients had RT, and most of these events (97%) were not associated with breath stacking. Detecting RT was associated with lower tidal volume (Vt) and less opiate infusion. The presence of RT was not associated with time to discontinuation of mechanical ventilation (subdistribution hazard ratio, 1.03; 95% CI, 0.6-1.77), but it possibly was associated with a reduced hospital mortality (hazard ratio, 0.65; 95% CI, 0.57-0.73). INTERPRETATION: Fifty percent of patients receiving assist-control ventilation for mild or moderate ARDS, sedated and nonparalyzed, demonstrate RT without breath stacking on the first day of mechanical ventilation. RT may be associated with low Vts. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02732041; URL: www.clinicaltrials.gov.

9.
Medicina (B.Aires) ; 80(4): 397-400, ago. 2020. graf
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1154836

RESUMO

Resumen La traqueobronquitis aspergilar es una forma poco frecuente de aspergilosis invasiva reportada excepcionalmente en el paciente inmunocompetente. Su diagnóstico es difícil, y los tratamientos propuestos hasta ahora son de escasa efectividad, todo lo cual constituye un verdadero problema para el equipo de salud. Presentamos el caso de una paciente de 28 años, inmunocompetente y sin antecedentes epidemiológicos, que desarrolló traqueobronquitis necrotizante por aspergilosis invasiva y recibió tratamiento con voriconazol con instilación local por broncoscopia con buena respuesta.


Abstract Aspergillus tracheobronchitis is a rare form of invasive aspergillosis reported exceptionally in the immunocompetent patient. Its diagnosis is difficult, and the treatments proposed so far are of little effectiveness, all of which constitute a real problem for the health team. We present the case of an immunocompetent 28 yearsold woman, with no epidemiological background, who developed necrotizing tracheobronchitis due to invasive aspergillosis and received voriconazole with local instillation by bronchoscopy with a good response.

10.
Medicina (B Aires) ; 80 Suppl 3: 25-30, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32658844

RESUMO

This is an analysis of clinical characteristics, images findings, laboratory variables and respiratory mechanics in patients with coronavirus disease 2019 (COVID-19) during the first month of the pandemic outbreak in Buenos Aires. In this descriptive case study of a single-centre, we included all confirmed cases of COVID-19 hospitalized in intensive care unit (ICU). All cases were confirmed by reverse transcription polymerase chain reaction. A total of 7 patients with confirmed COVID-19 were referred to out ICU. The median age was 71 years (interquartile range 52-75), including 4 men and 3 women. Patients most common clinical manifestations were fever (7), cough (5), asthenia (4) and shortness of breath (3). Among the radiological findings, five of them showed interstitial opacities and one patient had bilateral pulmonary consolidation. Five required invasive mechanical ventilation and multiple prone sessions. None died during hospitalization, although three still remain in the ICU. According to imaging examination, 71.4% showed interstitial opacities and one patient bilateral consolidation. Five patients required invasive mechanical ventilation and multiple prone sessions. None of them died during hospitalization, although three still remain in the ICU.


Assuntos
Infecções por Coronavirus/diagnóstico , Coronavirus/isolamento & purificação , Unidades de Terapia Intensiva/organização & administração , Pandemias , Pneumonia Viral/diagnóstico , Respiração Artificial , Insuficiência Respiratória/terapia , Idoso , Argentina/epidemiologia , Astenia/etiologia , Betacoronavirus , Coronavirus/genética , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Tosse/etiologia , Dispneia/etiologia , Feminino , Febre/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
Medicina (B.Aires) ; 80(supl.3): 25-30, June 2020. ilus, graf, tab
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1135187

RESUMO

Se trata de un análisis de características clínicas, hallazgos radiológicos, variables de laboratorio y mecánica respiratoria en pacientes con enfermedad por coronavirus 2019 (COVID-19) durante el primer mes de la pandemia en Buenos Aires. Es un estudio descriptivo de casos, de un solo centro. Se incluyeron todos los casos confirmados de COVID-19 internados en la unidad de terapia intensiva de adultos (UTIA) del Hospital Italiano de Buenos Aires. Todos los casos se confirmaron por reacción en cadena de la polimerasa con transcriptasa inversa. Un total de 7 pacientes con COVID-19 fueron atendidos en la UTIA. La mediana de edad fue de 71 años (intervalos intercuartílicos: 52-75), 4 hombres y 3 mujeres. Las manifestaciones clínicas más comunes fueron fiebre (7), tos (5), astenia (4) y disnea (3). Entre los hallazgos radiológicos, cinco de ellos mostraron opacidades intersticiales y un paciente consolidación pulmonar bilateral. Cinco requirieron ventilación mecánica invasiva y múltiples sesiones de decúbito prono. Ninguno murió durante la hospitalización, aunque aún tres permanecen en UCI.


This is an analysis of clinical characteristics, images findings, laboratory variables and respiratory mechanics in patients with coronavirus disease 2019 (COVID-19) during the first month of the pandemic outbreak in Buenos Aires. In this descriptive case study of a single-centre, we included all confirmed cases of COVID-19 hospitalized in intensive care unit (ICU). All cases were confirmed by reverse transcription polymerase chain reaction. A total of 7 patients with confirmed COVID-19 were referred to out ICU. The median age was 71 years (interquartile range 52-75), including 4 men and 3 women. Patients most common clinical manifestations were fever (7), cough (5), asthenia (4) and shortness of breath (3). Among the radiological findings, five of them showed interstitial opacities and one patient had bilateral pulmonary consolidation. Five required invasive mechanical ventilation and multiple prone sessions. None died during hospitalization, although three still remain in the ICU. According to imaging examination, 71.4% showed interstitial opacities and one patient bilateral consolidation. Five patients required invasive mechanical ventilation and multiple prone sessions. None of them died during hospitalization, although three still remain in the ICU.

12.
Rev. Hosp. Ital. B. Aires (2004) ; 40(2): 53-55, jun. 2020. ilus
Artigo em Espanhol | LILACS | ID: biblio-1102484

RESUMO

Una de las características de la afección pulmonar por enfermedad por coronavirus (COVID-19) es la disociación entre la gravedad de la hipoxemia y el mantenimiento de una mecánica respiratoria relativamente conservada. En este contexto se ha establecido una teoría en relación con dos fenotipos de pacientes con síndrome de distrés respiratorio del adulto (SDRA): un fenotipo Low, caracterizado por baja elastancia y baja reclutabilidad, y un fenotipo High, con características de alta elastancia y alta reclutabilidad. Presentamos el caso de un paciente que cursó internación en la Unidad de Terapia Intensiva de Adultos de nuestro hospital, con clínica, mecánica ventilatoria y patrón tomográfico compatible con el fenotipo Low de SDRA por COVID-19. (AU)


Dissociation between severity of hypoxemia and relative preserved respiratory mechanics is a characteristic observed in lung impairment due to coronavirus disease (COVID-19). Patients with COVID-19 that present adult respiratory distress syndrome (ARDS) are identified for one of two phenotypes according to a theory recently established. The Low phenotype is distinguished by low elastance and low recruitability; and the High phenotype, by high elastance and high recruitability. The case describes a patient admitted in the adult Intensive Care Unit of Hospital Italiano de Buenos Aires with observed symptoms, ventilatory mechanics and tomographic pattern that are compatible with Low phenotype of ARDS due to COVID-19. (AU)


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Síndrome do Desconforto Respiratório do Adulto/microbiologia , Infecções por Coronavirus/terapia , Fenótipo , Síndrome do Desconforto Respiratório do Adulto/genética , Mecânica Respiratória , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/fisiopatologia , Tosse/etiologia , Dispneia/etiologia , Febre/etiologia , Hipertensão/complicações , Unidades de Terapia Intensiva , Hipóxia/fisiopatologia , Obesidade/complicações
13.
Neurocrit Care ; 2020 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-32346842

RESUMO

BACKGROUND: Family of patients hospitalized in an intensive care unit (ICU) often immediately assume the role of caregiver to an individual with significant health care needs. The transition into this caregiver role may be sudden and unexpected; their experiences are not well understood. The purpose of this qualitative study was to explore experiences of family caregivers in the neurocritical care unit in order to identify areas for enhancing patient- and family-centered care. METHODS: This single-center ethnographic study explored the use of systems theory to investigate the perceptions, experiences, and attitudes of family/caregivers regarding their relationships and interactions between the patient, other family, members of the healthcare provider team, and health system after an acute neurological event in Argentina. Field notes from 9 weeks of direct observation together with transcripts from nine semi-structured interviews (transcribed verbatim and translated from Spanish to English) were analyzed using a grounded theory approach. RESULTS: Nine themes emerged based on iterative thematic analysis, including: adjusting to a changed life, managing emotions, changing role, relying on faith, redefining recovery, participating in patient care, depending on clinical experts, el tratohumano, and finding unity in purpose. In the neurocritical care environment, an important intermediary role exists for family/caregivers and the patient, other family, and healthcare providers. CONCLUSIONS: The results demonstrate the potential for family, providers, and the health system to influence family/caregivers' experience with neurocritical care. Involving families as part of the care team could have implications for patient- and family-centered care.

14.
Arch Bronconeumol ; 2020 Feb 13.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32063391
15.
J Clin Monit Comput ; 34(6): 1239-1246, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31853811

RESUMO

Asynchrony due to reverse-triggering (RT) may appear in ARDS patients. The objective of this study is to validate an algorithm developed to detect these alterations in patient-ventilator interaction. We developed an algorithm that uses flow and airway pressure signals to classify breaths as normal, RT with or without breath stacking (BS) and patient initiated double-triggering (DT). The diagnostic performance of the algorithm was validated using two datasets of breaths, that are classified as stated above. The first dataset classification was based on visual inspection of esophageal pressure (Pes) signal from 699 breaths recorded from 11 ARDS patients. The other classification was obtained by vote of a group of 7 experts (2 physicians and 5 respiratory therapists, who were trained in ICU), who evaluated 1881 breaths gathered from recordings from 99 subjects. Experts used airway pressure and flow signals for breaths classification. The RT with or without BS represented 19% and 37% of breaths in Pes dataset while their frequency in the expert's dataset were 3% and 12%, respectively. The DT was very infrequent in both datasets. Algorithm classification accuracy was 0.92 (95% CI 0.89-0.94, P < 0.001) and 0.96 (95% CI 0.95-0.97, P < 0.001), in comparison with Pes and experts' opinion. Kappa statistics were 0.86 and 0.84, respectively. The algorithm precision, sensitivity and specificity for individual asynchronies were excellent. The algorithm yields an excellent accuracy for detecting clinically relevant asynchronies related to RT.

16.
Respir Care ; 65(1): 11-20, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31615922

RESUMO

BACKGROUND: The difference between Bohr and Enghoff dead space are not well described in ARDS patients. We aimed to analyze the effect of PEEP on the Bohr and Enghoff dead spaces in a model of ARDS. METHODS: 10 pigs submitted to randomized PEEP steps of 0, 5, 10, 15, 20, 25 and 30 cm H2O were evaluated with the use of lung ultrasound images, alveolar-arterial oxygen difference (P(A-a)O2 ), transpulmonary mechanics, and volumetric capnography at each PEEP step. RESULTS: At PEEP ≥ 15 cm H2O, atelectasis and P(A-a)O2 progressively decreased while end-inspiratory transpulmonary pressure (PL), end-expiratory PL, and driving PL increased (all P < .001). Bohr dead space (VDBohr /VT), airway dead space (VDaw /VT), and alveolar dead space (VDalv /VTalv ) reached their highest values at PEEP 30 cm H2O (0.69 ± 0.10, 0.53 ± 0.13 and 0.35 ± 0.06, respectively). At PEEP <15 cm H2O, the increases in atelectasis and P(A-a)O2 were associated with negative end-expiratory PL and highest driving PL. VDBohr /VT and VDaw /VT showed the lowest values at PEEP 0 cm H2O (0.51 ± 0.08 and 0.32 ± 0.08, respectively), whereas VDalv /VTalv increased to 0.27 ± 0.05. Enghoff dead space and its derived VDalv /VTalv showed high values at low PEEPs (0.86 ± 0.02 and 0.79 ± 0.04, respectively) and at high PEEPs (0.84 ± 0.04 and 0.65 ± 0.12), with the lowest values at 15 cm H2O (0.77 ± 0.05 and 0.61 ± 0.11, respectively; all P < .001). CONCLUSIONS: Bohr dead space was associated with lung stress, whereas Enghoff dead space was partially affected by the shunt effect.


Assuntos
Respiração com Pressão Positiva/métodos , Espaço Morto Respiratório , /terapia , Animais , Capnografia , Pulmão , Modelos Teóricos , Atelectasia Pulmonar , Suínos , Volume de Ventilação Pulmonar
17.
Medicina (B Aires) ; 79(6): 506-508, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31829954

RESUMO

The arteriovenous extracorporeal membrane is used in patients with hemodynamic and respiratory failure, unresponsive to conventional treatment. It provides transitory hemodynamic support, oxygenation and removal of CO2, allowing pulmonary rest. Moreover it offers the possibility of ultraprotective ventilation and avoids generation of VILI (Ventilation-Induced Lung Injury). It is not frequently used in patients with hemodynamic failure secondary to obstructive shock due to mediastinal compromise. We present the case of a patient with obstructive shock, mediastinal mass of lymphoproliferative origin that was treated with extracorporeal arteriovenous circulation membrane.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Linfoma Difuso de Grandes Células B/complicações , Insuficiência Respiratória/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Adulto , Angiografia por Tomografia Computadorizada/métodos , Feminino , Hemodinâmica , Humanos , Linfoma Difuso de Grandes Células B/diagnóstico por imagem , Linfoma Difuso de Grandes Células B/patologia , Choque Cardiogênico/diagnóstico por imagem , Tomografia por Raios X/métodos , Resultado do Tratamento
18.
Medicina (B.Aires) ; 79(6): 506-508, dic. 2019. ilus
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1056760

RESUMO

La membrana de oxigenación extracorpórea arteriovenosa se utiliza cuando ocurre falla hemodinámica y respiratoria refractaria al tratamiento convencional; brinda soporte hemodinamico transitorio, oxigenacion y remocion de CO2, y permite reposo pulmonar. Asimismo ofrece la posibilidad de realizar ventilación ultraprotectiva y evitar la generación de VILI (Ventilation-Induced Lung Injury). No ha sido demostrada su utilización como una terapia frecuente en los casos con insuficiencia hemodinámica secundaria a shock obstructivo por afectación mediastínica. Presentamos el caso de un paciente con shock obstructivo por una masa mediastínica de origen linfoproliferativo tratada con membrana de circulación arteriovenosa extracorpórea.


The arteriovenous extracorporeal membrane is used in patients with hemodynamic and respiratory failure, unresponsive to conventional treatment. It provides transitory hemodynamic support, oxygenation and removal of CO2, allowing pulmonary rest. Moreover it offers the possibility of ultraprotective ventilation and avoids generation of VILI (Ventilation-Induced Lung Injury). It is not frequently used in patients with hemodynamic failure secondary to obstructive shock due to mediastinal compromise. We present the case of a patient with obstructive shock, mediastinal mass of lymphoproliferative origin that was treated with extracorporeal arteriovenous circulation membrane.

19.
J Crit Care ; 45: 231-238, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29754942

RESUMO

PURPOSE: To analyze the effects of positive end-expiratory pressure (PEEP) on Bohr's dead space (VDBohr/VT) in patients with acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS: Fourteen ARDS patients under lung protective ventilation settings were submitted to 4 different levels of PEEP (0, 6, 10, 16 cmH2O). Respiratory mechanics, hemodynamics and volumetric capnography were recorded at each protocol step. RESULTS: Two groups of patients responded differently to PEEP when comparing baseline with 16-PEEP: those in which driving pressure increased > 15% (∆P˃15%, n = 7, p = .016) and those in which the change was ≤15% (∆P≤15%, n = 7, p = .700). VDBohr/VT was higher in ∆P≤15% than in ∆P≤15% patients at baseline ventilation [0.58 (0.49-0.60) vs 0.46 (0.43-0.46) p = .018], at 0-PEEP [0.50 (0.47-0.54) vs 0.41 (0.40-0.43) p = .012], at 6-PEEP [0.55 (0.49-0.57) vs 0.44 (0.42-0.45) p = .008], at 10-PEEP [0.59 (0.51-0.59) vs 0.45 (0.44-0.46) p = .006] and at 16-PEEP [0.61 (0.56-0.65) vs 0.47 (0.45-0.48) p = .001]. We found a good correlation between ∆P and VDBohr/VT only in the ∆P˃15% group (r = 0.74, p < .001). CONCLUSIONS: Increases in PEEP result in higher VDBohr/VT only when associated with an increase in driving pressure.


Assuntos
/fisiopatologia , Adulto , Idoso , Capnografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Espaço Morto Respiratório , /terapia
20.
Med. crít. (Col. Mex. Med. Crít.) ; 31(4): 224-229, jul.-ago. 2017. tab, graf
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1040431

RESUMO

Resumen: Introducción: El soporte vital extracorpóreo (ECLS - por sus siglas en inglés extra-corporeal life support) se aplica exitosamente en neonatos con insuficiencia respiratoria aguda (IRA). Las dificultades técnicas, los costos y los resultados desalentadores confinaron a esta técnica como última estrategia en adultos. Nuestro objetivo es reportar nuestra experiencia con ECLS en adultos. Material y métodos: Se analizaron pacientes adultos tratados con ECLS entre febrero de 2002 y enero de 2012. Se recolectaron variables demográficas y cardiopulmonares. Los datos son expresados como mediana (rango). Se analizaron las diferencias entre los pacientes afectados con IRA aislada y con síndrome cardiopulmonar por Hantavirus (SCPH) con test U de Mann Whitney y se consideró estadísticamente significativo un valor de p < 0.05. Resultados: Se aplicó ECLS a15 pacientes. Cinco venoarteriales (VA), siete venovenoso (V-V) y tres asistencias pulmonares extracorpóreas sin bomba (P-ELA). Se describen variables demográficas, cardiopulmonares, diagnóstico, tiempo en ECLS y los desenlaces. Los días en ventilación mecánica (VM), la estadía en UCI y hospital fueron: 17 (4-49), 38 (4-93) y 46 (4-102) días respectivamente. Siete de los 15 pacientes fallecieron (47%). Dos pacientes murieron por shock séptico por bacilos Gram negativos después de un ECLS exitoso. La única diferencia estadísticamente significativa entre los pacientes con IRA aislada (ECLS-VV venovenosa o P-ELA) y los pacientes con SCPH (ECLS-VA venoarterial) fue el lactato al ingreso (p < 0.05). Conclusión: ECLS es una estrategia útil como rescate de adultos con IRA refractaria a estrategias de VM avanzada. El progreso en los equipos y el uso de algoritmos en la toma de decisiones han contribuido a reducir la morbimortalidad.


Abstract: Introduction: Extra-corporeal life support (ECLS) is an established technique for neonates with acute respiratory failure (ARF). Technical difficulties, expense and discouraging outcomes explains its confinement to a last resource tool for adults with ARF. Our objective is report the experience with adult ECLS in two hospitals. Material and methods: All consecutive adult patients treated with different ECLS techniques from 2002 to 2012 were analyzed. Demographic and cardiopulmonary variables were collected. Data are expressed as median (range). The differences between patients affected with ARF isolated and patients with hantavirus cardiopulmonary syndrome was obtained with Mann Whitney U test and a value of p < 0.05 was considered statistically significant. Results: Fifteen patients received ECLS. Five were veno-arterial (VA), 7 veno-venous (VV), and 3 pumpless extracorporeal lung assist (P-ELA). Demographic, cardiopulmonary variables, diagnosis, time on ECLS and outcome are described. Mechanical ventilation (MV), ICU and hospital stay were 17 (4-49), 38 (4-93) and 46 (4-102) days respectively. All patients who required VA-ECLS were affected for Hanta cardiopulmonary syndrome. Seven of fifteen patients died. Two out of five VA-ECLS suffered some degree of lower extremity (arterial cannulation) compartmental syndrome and a mild abnormal gait sequel affected them. Vascular accesses and bleeding were not a concern. Two patients died due to septic shock from gram negative bacilli after leaving ECLS. Conclusion: ECLS for catastrophic ARF in adults is useful therapeutic option to rescue patients who do not respond to conventional MV strategies. The progress in technical devices, use an algorithm to medical decision making contribute to reducing morbidity and mortality.


Resumo: Introdução: O suporte de vida extracorpórea (ECLS) é usado com sucesso em neonatos com insuficiência respiratória aguda (IRA). As dificuldades técnicas, custos e resultados decepcionantes confinaram a esta técnica como última estratégia em adultos. Nosso objetivo é relatar nossa experiência com ECLS em adultos. Métodos: Foram analisados pacientes adultos tratados com ECLS entre 2002 e 2012. Foram recolhidas as variáveis demográficas e cardiopulmonares. Os dados são expressos em mediana (desvio padrão). As diferenças entre os pacientes com IRA isolada e com síndrome cardiopulmonar por Hantavírus foi analisada com o teste U de Mann Whitney e foi considerou um valor estatisticamente significativo p < 0.05. Resultados: Quinze pacientes receberam ECLS. Cinco veno-arteriais (VA), 7 veno-venosas (V-V) e trêis asssistências pulmonares extracorpóreas sem bomba (P-ELA). Se descrevem variáveis demográficas, cardiopulmonar, diagnóstico, tempo no ECLS e os resultados. Os dias de ventilação mecânica (VM), tempo de UTI e hospitalar foram: 17 (4-49), 38 (4-93) e 46 (4-102) dias respectivamente. Sete dos quinze pacientes morreram (47%). Dois pacientes morreram com choque séptico por bacilos gram negativos depois de um ECLS exitoso. A única diferença estatisticamente significativa entre os pacientes com IRA isolada (ECLS-VV ou P-ELA) e pacientes com SCPH (ECLS-VA) foi o lactato na admissão (p < 0.05). Conclusão: O ECLS é uma estratégia útil como resgate de adultos com IRA refractária a estratégias de VM avançada. O progresso dos equipamentos e o uso de algoritmos na tomada de decisões têm ajudado a reduzir a morbimortalidade.

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