Trombolisis intravenosa en accidente cerebro vascular isquémico agudo en un hospital público de Chile: análisis prospectivo de 54 casos / Intravenous thrombolysis for ischemic stroke: experience in 54 patients

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) reduces disability in patients with ischemic stroke. However, its implementation in Chilean public general hospitals has been slow and faces some difficulties. Aim: To analyze the results of an intravenous thrombolysis protocol implementation in a public general hospital. Material and Methods: During a lapse of 28 months a standardized protocol for intravenous thrombolysis implemented in the emergency room of a public hospital, was prospectively evaluated. Fifty four patients with ischemic stroke were treated and assessed three months later as outpatients. Results: At three months of follow-up, 66.4% of patients subjected to thrombolysis had a favorable evolution, defined as having 0 to 1 points in the modified Rankin scale. Intracerebral hemorrhage rate was 11.1%, including 5.5% of symptomatic intracerebral hemorrhage. Four percent of patients had systemic bleeding complications after thrombolysis. The mortality rate was 14.8%. Conclusions: The success rates, mortality, and complications rate were comparable to the results obtained in international studies, despite of the absence of a stroke unit to manage stroke and its complications.

Presión positiva continua en la vía aérea comparada con la respiración mecánica asistida en prematuros de 28 a 32 semanas de gestación con administración precoz de surfactante pulmonar / Nasal CPAP versus mechanical ventilation in 28 to 32-week preterm infants with early surfactant administration

Introducción. La presión positiva continua en la vía aérea ( Continuous Positive Airway Pressure , CPAP) es útil en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria, pero no se ha precisado si es mejor que la respiración mecánica asistida después de la administración precoz de surfactante pulmonar. Objetivo. Comparar la incidencia de eventos adversos en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria atendidos con surfactante y respiración mecánica asistida o CPAP de burbuja. Materiales y métodos. Se atendieron 147 neonatos con respiración mecánica asistida y 176 con CPAP, ninguno de los cuales presentaba asfixia perinatal o apnea. Resultados. La incidencia de fracaso de la CPAP fue de 6,5 % (IC 95% 11,3-22,8 %). Fallecieron 29 pacientes, 7 de los cuales habían recibido CPAP (4,0 %) y, 22, respiración mecánica asistida (15,0 %; p<0,001). El riesgo relativo (RR) de morir de quienes recibieron CPAP, comparado con el de quienes recibieron respiración mecánica asistida, fue de 0,27 (IC 95% 0,12-0,61), pero, al ajustar por los factores de confusión, el uso de CPAP no implicó mayor riesgo de morir (RR=0,60; IC 95% 0,29-1,24). La letalidad con respiración mecánica asistida fue de 5,70 (IC 95% 3,75-8,66) muertes por 1.000 días-paciente, mientras que con CPAP fue de 1,37 (IC 95% 0,65-2,88; p<0,001). La incidencia de neumopatía crónica fue menor con CPAP (RR=0,71, IC 95% 0,54-0,96), al igual que la de hemorragia cerebral (RR=0,28; IC 95% 0,09-0,84) y la de sepsis (RR=0,67; IC 95% 0,52-0,86), pero fue similar en cuanto a escapes de aire (RR=2,51; IC 95% 0,83-7,61) y enterocolitis necrosante (RR=1,68; IC 95% 0,59-4,81). Conclusión. La incidencia de neumopatía crónica, hemorragia ventricular y sepsis es menor con el uso de CPAP.

Introduction: Continuous positive airway pressure (CPAP) is useful in low birth weight infants with respiratory distress, but it is not known if it is a better alternative to mechanical ventilation after early pulmonary surfactant administration. Objective: To compare the incidence of adverse events in 28 to 32-week newborns with respiratory distress managed with mechanical ventilation or CPAP after early surfactant administration. Materials and methods: In total, 176 newborns were treated with CPAP and 147 with mechanical ventilation, all with Apgar scores >3 at five minutes and without apnea. Results: The incidence of CPAP failure was 6.5% (95% CI: 11.3-22.8%); 29 patients died: 7 with CPAP (4.0%) and 22 with mechanical ventilation (15.0%, p<0.001). The relative risk of dying with CPAP versus mechanical ventilation was 0.27 (95% CI: 0.12-0.61), but after adjusting for confounding factors, CPAP use did not imply a higher risk of dying (RR=0.60; 95% CI: 0.29-1.24). Mechanical ventilation fatality rate was 5.70 (95% CI: 3.75-8.66) deaths/1,000 days-patient, while with CPAP it was 1.37 (95% CI: 0.65-2.88, p<0.001). Chronic lung disease incidence was lower with CPAP than with mechanical ventilation (RR=0.71; 95% CI: 0.54-0.96), as were intracranial hemorrhage (RR=0.28, 95% CI: 0.09-0.84) and sepsis (RR=0.67; 95%CI: 0.52-0.86), and it was similar for air leaks (RR=2.51; 95% CI: 0.83-7.61) and necrotizing enterocolitis (RR=1.68, 95% CI: 0.59-4.81). Conclusion: CPAP exposure of premature infants with respiratory distress syndrome is protective against chronic lung disease, intraventricular hemorrhage and sepsis compared to mechanical ventilation. No differences were observed regarding air leak syndrome or death.