Role of gastric ultrasound to guide enteral nutrition in the critically ill.

PURPOSE OF REVIEW: Early initiation of enteral nutrition (EN) is often not feasible due to the high prevalence of gastrointestinal dysfunction that constitutes one of the leading nonavoidable causes for discontinuing or delaying enteral feeding in critically ill. This review summarizes current evidence on the role of gastric ultrasound as a management and monitoring tool for enteral nutrition in critically ill patients. RECENT FINDINGS: The ultrasound meal accommodation test, the gastrointestinal and urinary track sonography (GUTS), and other gastric ultrasound protocols used to diagnose and treat gastrointestinal dysfunction in critically ill patients have not changed the outcome. However, this intervention could help clinicians with accurate daily clinical decisions. The dynamic changes in the cross-sectional area (CSA) diameter could help to access gastrointestinal dynamics results immediately, provide a valuable guide to initiate EN, predict feeding intolerance (FI), and aid in following treatment response. More studies are necessary to determine the complete scope and true added clinical value of these tests in critically ill patients. SUMMARY: Using gastric point of care ultrasound (POCUS) is a noninvasive, radiation-free, and inexpensive method. Implementing the ultrasound meal accommodation test in ICU patients might become a step forward to ensure safe early enteral nutrition in critically ill patients.

Open Fetal Microneurosurgery for Intrauterine Spina Bifida Repair.

OBJECTIVES: The aim of the study was to describe the feasibility of open fetal microneurosurgery for intrauterine spina bifida (SB) repair and to compare perinatal outcomes with cases managed using the classic open fetal surgery technique. METHODS: In this study, we selected a cohort of consecutive fetuses with isolated open SB referred to our fetal surgery center in Queretaro, Mexico, during a 3.5-year period (2016-2020). SB repair was performed by either classic open surgery (6- to 8-cm hysterotomy with leakage of amniotic fluid, which was replaced before uterine closure) or open microneurosurgery, which is a novel technique characterized by a 15- to 20-mm hysterotomy diameter, reduced fetal manipulation by fixing the fetal back, and maintenance of normal amniotic fluid and uterine volume during the whole surgery. Perinatal outcomes of cases operated with the classic open fetal surgery technique and open microneurosurgery were compared. RESULTS: Intrauterine SB repair with a complete 3-layer correction was successfully performed in 60 cases either by classic open fetal surgery (n = 13) or open microneurosurgery (n = 47). No significant differences were observed in gestational age (GA) at fetal intervention (25.4 vs. 25.1 weeks, p = 0.38) or surgical times (107 vs. 120 min, p = 0.15) between both groups. The group with open microneurosurgery showed a significantly lower rate of oligohydramnios (0 vs. 15.4%, p = 0.01), preterm rupture of the membranes (19.0 vs. 53.8%, p = 0.01), higher GA at birth (35.1 vs. 32.7 weeks, p = 0.03), lower rate of preterm delivery <34 weeks (21.4 vs. 61.5%, p = 0.01), and lower rate of perinatal death (4.8 vs. 23.1%, p = 0.04) than the group with classic open surgery. During infant follow-up, the rate of hydrocephalus requiring ventriculoperitoneal shunting was similar between both groups (7.5 vs. 20%, p = 0.24). All patients showed an intact hysterotomy site at delivery. CONCLUSION: Intrauterine spina repair by open fetal microneurosurgery is feasible and was associated with better perinatal outcomes than classic open fetal surgery.

[Quantitative evaluation proposal of a ultrasonographic protocol for weaning from mechanichal ventilation]. / Propuesta de evaluación cuantitativa en el protocolo ultrasonográfico para retiro de la ventilación mecánica invasiva (GMEMI score).

INTRODUCTION: Mechanical ventilation is a therapy for vital support used in a significant proportion of critically ill patients. The right time to successfully discontinue this therapy is a challenge for the intensive care specialist. For this reason it is still a subject for research. The echocardiographic evaluation of the diastolic dysfunction, the diaphragm, and the lung have become an invaluable tool for weaning from mechanical ventilation protocols, especially in patients with difficult or prolonged weaning from mechanical ventilation. There is still a need to validate, in controlled trials, the efficacy of an ultrasound protocol for weaning from mechanical ventilation that integrates the three modalities in a single protocol. METHODS: Based on current literature, we developed a score justified by a mathematical model based on inequations. When χ ⇒ 5 the risk of failure in the weaning process rises, the weaning process should be suspended; when χ ⇒ 1 the risk of failure is low, the weaning process should be continued. CONCLUSIONS: The use of math models for decision-making is of great importance, as it sets an objective parameter within the existing evaluations. We proposed the use of inequations to set intervals of solution with the three points of care for ultrasound-guided weaning from mechanical ventilation. With this, the inequations proposed generate an area of certainty within the proposed values and the solution intervals.

[Use of thromboelastography and thromboelastometry for the rational and opportune transfusion of hemoderivatives in obstetric hemorrhage]. / Uso de tromboelastrografía y tromboelastometría para la transfusión racional y oportuna de hemoderivados en hemorragia obstétrica.

Obstetric hemorrhage is the leading cause of maternal mortality, responsible of 143,000 deaths every year. Thromboelastography is a tool that allows measuring the viscoelastic, dynamic and global properties of the blood, offering valuable information of coagulation alterations and help to guide early goal directed transfusional therapy. The purpose of this review is to evaluate the evidence of this tool in obstetric hemorrhage and the management of the associated coagulopathy.

Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

Neutrophil-mediated Inflammatory Plasminogen Degradation, Rather Than High Plasminogen-Activator Inhibitor-1, May Underly Failures and Inefficiencies of Intrapleural Fibrinolysis.

BACKGROUND: Complex pleural space infections often require treatment with multiple doses of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease, with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would show high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation. RESEARCH QUESTION: Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure? STUDY DESIGN AND METHODS: We obtained infected pleural fluid and circulating plasma from hospitalized adults (n = 10) with institutional review board approval from a randomized trial evaluating intrapleural fibrinolytics vs surgery for initial management of pleural space infection. Samples were collected before the intervention and on days 1, 2, and 3 after the intervention. Activity assays, enzyme-linked immunosorbent assays, and Western blot analysis were performed, and turbidimetric measurements of fibrinolysis were obtained from pleural fluid with and without exogenous plasminogen supplementation. Results are reported as median (interquartile range) or number (percentage) as appropriate, with an α value of .05. RESULTS: Pleural fluid elastase activity was more than fourfold higher (P = .02) and plasminogen antigen levels were more than threefold lower (P = .04) than their corresponding plasma values. Pleural fluid Western blot analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen activator inhibitor 1 (PAI-1), the native tPA inhibitor, showed high antigen levels before the intervention, but the overwhelming majority of this PAI-1 (82%) was not active (P = .003), and all PAI-1 activity was lost by day 2 after the intervention in patients receiving intrapleural tPA and deoxyribonuclease. Finally, using turbidity clot lysis assays, we found that the pleural fluid of 9 of 10 patients was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients. INTERPRETATION: Our findings suggest that inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03583931; URL: www. CLINICALTRIALS: gov.

A Review of the Usefulness of Catheter-Directed Thrombolysis for Pulmonary Embolism.

Venous thromboembolic disease (VTE) is a health problem; around 10 million cases occur yearly with substantial morbidity and mortality. Those who survive may be left with long-term sequelae. Those sequelae might include chronic thromboembolic pulmonary hypertension, persistent right ventricular dysfunction, exercise intolerance, and reduced quality of life. Current PE management consists of anticoagulation alone, systemic thrombolysis, catheter-directed thrombolysis, and surgical embolectomy. The severity of patients with pulmonary embolism (PE) depends on the clinic and not exclusively on the extent of radiological or anatomical involvement. In this review, we present the main clinical and functional characteristics of patients in whom thrombotic fragmentation plus catheter-guided thrombolysis is used to manage acute PE of intermediate-high risk and torpid evolution within the first hours of admission.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH): A Review of Another Sequel of Severe Post-Covid-19 Pneumonia.

The spectrum of pulmonary parenchymal and vascular pathologies related to the COVID-19 have emerged. There is evidence of a specific susceptibility related to thrombotic microangiopathy in situ and a complex immune-inflammatory cascade, especially in the pulmonary vascular bed. The potential to lead to transient or self-correcting sequelae of pulmonary vascular injury will only become apparent with longer-term follow-up. In this review, we aimed to present the findings in a group of patients with severe pneumonia due to covid-19 complicated by acute pe documented by chest angiography, who during a follow-up of more than 3 months with oral anticoagulant met clinical, hemodynamic, and imaging criteria of chronic thromboembolic pulmonary hypertension. We present a brief review of the epidemiology, pathophysiology, clinical findings, comorbidities, treatment, and imaging findings of chronic thromboembolic pulmonary hypertension as a sequel of severe post-covid-19 pneumonia; and compared and discussed these findings with similar reports from the medical literature.

Pulmonary Embolism (PE) Prevalence in Mexican-Mestizo Patients With Severe SARS-COV-2 (COVID-19) Pneumonia At A Tertiary-Level Hospital: A Review.

Since the report of the first case of COVID-19 in Wuhan, China, on December 31, 2019, several associated thrombotic complications have been reported, mainly venous thromboembolic events, and myocardial infarctions, in addition to peripheral arterial thrombosis and cerebral vascular events, which have been attributed to a hypercoagulable state. We aimed to know the prevalence and prognostic biomarkers in patients with pulmonary thromboembolism (PE) and SARS Cov-2 pneumonia. Hospitalized patients with SARS Cov-2 pneumonia who have had clinical, biomarker, and imaging data (chest angiography) of pulmonary thromboembolism were included. Descriptive statistics and prevalence rates were calculated. For the analysis between the groups, the paired Student's t and the Wilcoxon test were performed. CT angiography was performed on 26 patients at our institution, with a diagnosis of severe pneumonia secondary to SARS-CoV2. 9 of the patients (34.6%) had a venous thromboembolic disease. Type 2 DM was the most frequent comorbidity up to 55.5% of the total; it was followed by obesity and overweight in 55.5%, and in third place, by systemic arterial hypertension in 33.3% of the cases, 1 (11.1%) patient had chronic kidney disease and 1 (11.1%) patient with a history of cancer, only 1 patient met criteria and was treated with thrombolysis. 6 (66.6%) of the patients had segmental PE, 3 (33.3%) patients had subsegmental PE, and 4 (44.4%) patients presented pulmonary infarction.

Patient Blood Management in Liver Transplant-A Concise Review.

Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.

Ultrasound meal accommodation test in critically ill patients with and without feeding intolerance UMAT-ICU.

BACKGROUND: Gastrointestinal dysfunction (GID) is one of the leading causes of nonavoidable discontinuing or delayed enteral feeding in critically ill patients. The ultrasound meal accommodation test (UMAT) has been used in ambulatory patients to evaluate dyspepsia. The objective of this study was to determine differences in the UMAT scores of critically ill patients with and without feeding intolerance (FI). METHODS: A prospective, observational, two-centre study was conducted between June and August 2019. We included subjects who met the criteria for enteral nutrition. Patients and their subrogates provided signed consent for intervention. The independent variables were cross-sectional area (CSA) and calculated gastric volume (CGV). Dependent variables were changes in the UMAT at Time 1 and Time 2 and gastric residue in those with and without FI. After that, patients were divided into two groups, depending on the development of GID over the following 48 h after inclusion in the study group A, subjects without FI; and group B, subjects with FI. According to the normal distribution in parametric or non-parametric tests. Differences between groups were determined using a Student's T-test. A p-value of ≤0.05 was established for the statistical difference between groups. At 60 min, a change cut-off point of 52% has a sensitivity of 50%, specificity of 88.9%, a positive likelihood ratio of 4.50 and a negative likelihood ratio of 0.56. With a pretest probability of 85% for feeding tolerance in intensive care unit patients, the posttest probability increased to 96% with a positive test with the ΔCSA. RESULTS: 61 patients were included in the study; 52 (85%) in Group A and 9 (15%) in Group B. However, at time 0 (fasting), there were statistical differences in CSA and CGV between groups (p = 0.001). During Time 1 (dynamic changes), there were statistical differences between the groups (p = 0.008 for CSA and p = 0.011 for CGV). At time 3 (Delta), there were statistical differences between groups at minute 10 (p = 0.023 for CSA and p = 0.008 for CGV). CONCLUSION: Our study showed statistical differences in the UMAT test between patients with and without FI. TRIAL REGISTRATION: Clinical trials registry NCT03851354. February 22, 2019.

Prospective multicenter study of heart rate variability with ANI monitor as predictor of mortality in critically ill patients with COVID-19.

The purpose of this study is to demonstrate that the most critically ill patients with COVID-19 have greater autonomic nervous system dysregulation and assessing the heart rate variability, allows us to predict severity and 30-day mortality. This was a multicentre, prospective, cohort study. Patients were divided into two groups depending on the 30-day mortality. The heart rate variability and more specifically the relative parasympathetic activity (ANIm), and the SDNN (Energy), were measured. To predict severity and mortality multivariate analyses of ANIm, Energy, SOFA score, and RASS scales were conducted. 112 patients were collected, the survival group (n = 55) and the deceased group (n = 57). The ANIm value was higher (p = 0.013) and the Energy was lower in the deceased group (p = 0.001); Higher Energy was correlated with higher survival days (p = 0.009), and a limit value of 0.31 s predicted mortalities with a sensitivity of 71.9% and a specificity of 74.5%. Autonomic nervous system and heart rate variability monitoring in critically ill patients with COVID-19 allows for predicting survival days and 30-day mortality through the Energy value. Those patients with greater severity and mortality showed higher sympathetic depletion with a predominance of relative parasympathetic activity.

In Situ Pulmonary Thrombolysis and Perfusion Lung Angiography in Severe COVID-19 Respiratory Failure.

A proof-of-concept study using thrombolysis with catheter-directed tissue plasminogen activator (tPA) and pulmonary angiography imaging was performed to visualize perfusion deficits and reperfusion/therapeutic effects of tPA. DESIGN: A prospective, open-label, compassionate study. Descriptive statistics were presented for categorical variables and as means with sds for continuous variables. The Wilcoxon test was used to determine the differences between the two-related samples and a t test for continuous variables. Statistical significance was set at p value of less than 0.05. Agreement between observations was evaluated using the Kappa Cohen index and overall agreement using the Fleiss Kappa coefficient. SETTING: A single COVID-19 ICU of Mexico´s General Hospital Dr Eduardo Liceaga. SUBJECTS: Fifteen patients with severe Delta variant severe acute respiratory syndrome coronavirus 2 infection, 18-75 years old, requiring mechanical ventilation with a persistent Fio2 requirement of 70% or higher and Pao2/Fio2 ratio (or imputed ratio) less than 150 for more than 4 hours. The coagulation inclusion criteria were International Society on Thrombosis and Haemostasis score greater than 5, and presence of a d-dimer greater than 1,200, with viscoelastic testing using rotational thromboelastometry (Instrumentation Laboratories, Mexico City, Mexico) showing both hypercoagulability (EXTEM amplitude at 5 min > 65 FIBTEM > 30) and hypofibrinolysis (EXTEM maximum lysis < 8%). INTERVENTIONS: Catheter-directed tPA angiography and iFlow system analysis to assess pre-tPA baseline pulmonary perfusion and changes in response to thrombolysis. RESULTS: Nine patients had microvascular filling defects demonstrated by angiography, and good agreement was found with iFlow analysis (ƙ = 0.714). Statistically significant differences were identified in the area under the curve (AUC) region of interest/AUC reference tissue with and without filling defects in phase 2 DM -0.09206 (sd ± 0.16684) (p = 0.003). The Pao2/Fio2 values measured immediately and 48 hours after the procedure were significantly higher (p = 0.001 and p = 0.005, respectively). Statistically significant differences were found in d-dimer values (p = 0.007), Fio2 (p = 0.002), and oxygen saturation in arterial blood/Fio2 (p = 0.045), as well as in the number of patients who required prone positioning before, immediately after the procedure, and at 48 hours after the procedure (p = 0.002). CONCLUSIONS: Thrombolysis with catheter-directed tPA resulted in imaging evidence via pulmonary angiography and iFlow technology of improved lung perfusion in COVID-19 patients with severe respiratory failure.

Environmental Nanoparticles Reach Human Fetal Brains.

Anthropogenic ultrafine particulate matter (UFPM) and industrial and natural nanoparticles (NPs) are ubiquitous. Normal term, preeclamptic, and postconceptional weeks(PCW) 8-15 human placentas and brains from polluted Mexican cities were analyzed by TEM and energy-dispersive X-ray spectroscopy. We documented NPs in maternal erythrocytes, early syncytiotrophoblast, Hofbauer cells, and fetal endothelium (ECs). Fetal ECs exhibited caveolar NP activity and widespread erythroblast contact. Brain ECs displayed micropodial extensions reaching luminal NP-loaded erythroblasts. Neurons and primitive glia displayed nuclear, organelle, and cytoplasmic NPs in both singles and conglomerates. Nanoscale Fe, Ti, and Al alloys, Hg, Cu, Ca, Sn, and Si were detected in placentas and fetal brains. Preeclamptic fetal blood NP vesicles are prospective neonate UFPM exposure biomarkers. NPs are reaching brain tissues at the early developmental PCW 8-15 stage, and NPs in maternal and fetal placental tissue compartments strongly suggests the placental barrier is not limiting the access of environmental NPs. Erythroblasts are the main early NP carriers to fetal tissues. The passage of UFPM/NPs from mothers to fetuses is documented and fingerprinting placental single particle composition could be useful for postnatal risk assessments. Fetal brain combustion and industrial NPs raise medical concerns about prenatal and postnatal health, including neurological and neurodegenerative lifelong consequences.

Convalescent Plasma to Treat COVID-19: A Two-Center, Randomized, Double-Blind Clinical Trial.

Background: The use of convalescent plasma (CP) has been considered for its immunological mechanisms that could benefit patients in moderate and severe stages of COVID-19. This study evaluated the safety and efficacy of the use of donor CP for COVID-19. Material and methods: A double-blind, randomized controlled clinical trial was conducted from May to October 2020. Thirty-nine participants with moderate (II) and severe (III) stages of COVID-19 confirmed by RT-PCR were included. The study randomization rate was set at 3:1. CPs were chosen for application with a neutralizing antibody titer of ≥1:32. Results: We observed a significantly lower 21-day post-transfusion mortality HR: 0.17 (95.0% CI [0.07−0.45, p < 0.001]) in the group receiving CP compared with the control group; protective units (PU) in the group receiving convalescent plasma after seven days were significantly higher (512 (32−16,384) vs. 96 (32−256), p = 0.01); the PAO2/FIO2 index showed a significant improvement in the group receiving CP (251.01 (109.4) vs. 109.2 (62.4), p < 0.001, in the control group). Conclusion: CP is safe and effective, as it decreased mortality in the CP group compared with the control group.

Observational Safety Study of Clottafact® Fibrinogen Concentrate: Real-World Data in Mexico.

BACKGROUND AND OBJECTIVE: The use of fibrinogen concentrate to treat or prevent major bleeding with regard to potential adverse reactions has not been free of controversy. Our objective was to perform a post-authorization safety study to describe the use of Clottafact® (LFB Biomedicaments) fibrinogen concentrate in real-life medical practice in Mexico. METHODS: This was a prospective, observational study that collected and evaluated information between January 2017 and June 2019 related to suspected serious adverse reactions (SUSARs) during and after Clottafact® infusion. RESULTS: Information from 40 subjects was analyzed; 43% were women (n = 17), mean age was 39.05 ± 26.8 years (range 0-91 years). The medical specialties included in this analysis were cardiac surgery - 52.5% of the cases, gynecology/obstetrics - 17.5%, general surgery and orthopedics - 12.5% each, and hematology and neurosurgery - 2.5%, respectively. Mean plasma fibrinogen levels before and after Clottafact® infusion were 2.58 g/L and 4.02 g/L; p = 0.001, respectively. The mean Clottafact® dose was 2.20 ± 0.77 g. One patient presented SUSARs (dry mouth and dysgeusia) with drug administration, which ceased after treatment discontinuation. CONCLUSIONS: In this real-life post-marketing study, the safety profile of Clottafact® was very similar to previous reports. Thus, Clottafact® shows a favorable safety profile in clinical practice.

Point-of-care gastrointestinal and urinary tract sonography in daily evaluation of gastrointestinal dysfunction in critically ill patients (GUTS Protocol).

There is currently a lack of universally accepted criteria for gastrointestinal (GI) failure or dysfunction in critical care. Moreover, the clinical assessment of intestinal function is notoriously difficult and thus often goes unrecognized, contributing to poor outcomes. A recent grading system has been proposed to define acute gastrointestinal injury (AGI) in conjunction with other organ function scores (e.g., SOFA). Ultrasonography has become widely accepted as a diagnostic tool for GI problems and pathology. We propose a sonographic examination of the abdomen, using the GUTS protocol (gastrointestinal and urinary tract sonography) in critically ill patients as part of the point-of-care ultrasound evaluation in patients with AGI. This article reviews possible applications of ultrasonography that may be relevant to monitor the GI function in critically ill patients. The GI ultrasound protocol (GUTS) focuses on four gastrointestinal endpoints: gastrointestinal diameter, mucosal thickness, peristalsis, and blood flow. Moreover, it is possible to examine the urinary tract and kidney function. Real-time ultrasound with the GUTS protocol is a simple, inexpensive, bedside imaging technique that can provide anatomical and functional information of the GI tract. Further studies are needed to investigate the utility of GUTS with other parameters, such as GI biomarkers, AGI class, and clinical outcomes.

Tromboelastometría rotacional, el electrocardiograma de la coagulación / Rotational thromboelastometry. The electrocardiogram of coagulation

Resumen: La tromboelastometría evalúa los cambios viscoelásticos en el proceso de coagulación. Nos ofrece una representación gráfica de la formación del coágulo, la estabilidad del mismo y la presencia de lisis. La tromboelastometría rotacional es una herramienta diagnóstica que representa de forma gráfica la funcionalidad del coágulo para un manejo dirigido e individualizado de la coagulopatía asociada a hemorragia. En este trabajo se puntualiza cómo la tromboelastometría rotacional es a la coagulación como el electrocardiograma es al corazón.

Abstract: Thromboelastometry evaluates viscoelastic changes in the coagulation process. It offers us a graphic representation of the formation of the clot, its stability and the presence of lysis. Rotational thromboelastometry is a diagnostic tool that graphs the functionality of the clot, for a targeted and individualized management of bleeding-associated coagulopathy. In this work it is specified how rotational thromboelastometry is to coagulation as the electrocardiogram is to the heart.

[Metabolic control in the critically ill patient an update: hyperglycemia, glucose variability hypoglycemia and relative hypoglycemia]. / Actualidades en el control metabólico del paciente crítico: hiperglucemia, variabilidad de la glucosa, hipoglucemia e hipoglucemia relativa.

BACKGROUND: Metabolic changes of glucose in critically ill patients increase morbidity and mortality. The appropriate level of blood glucose has not been established so far and should be adjusted for different populations. However concepts such as glucose variability and relative hypoglycemia of critically ill patients are concepts that are changing management methods and achieving closer monitoring. OBJECTIVES: The purpose of this review is to present new data about the management and metabolic control of patients in critical areas. CONCLUSIONS: Currently glucose can no longer be regarded as an innocent element in critical patients; both hyperglycemia and hypoglycemia increase morbidity and mortality of patients. Protocols and better instruments for continuous measurement are necessary to achieve the metabolic control of our patients.

[Atipical uremic hemolityc syndrome in pregnancy]. / Síndrome urémico hemolítico atípico en el embarazo.

Atypical haemolytic uraemic syndrome is one of the main variants of thrombotic microangiopathy, and is characterized by excessive complement activation in the microvasculature. It is also characterised by the clinical triad; non-immune haemolytic anaemia, thrombocytopenia, and acute renal failure. In addition, 60% of patients have mutations in the genes encoding complement regulators (factor H, factor I, membrane cofactor proteins, and thrombomodulin), activators (factor B and C3), as well as autoantibodies against factor H. Multiple factors are required for the disease to manifest itself, including a trigger and gene mutations with adequate penetration. Being one of the differential diagnoses of preeclampsia- eclampsia and HELLP syndrome means that the clinician must be familiar with the disease due to its high mortality, which can be modified with early diagnosis and comprehensive treatment.