Percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis: Mortality and complications. / La gastrostomía endoscópica percutánea en pacientes diagnosticados de esclerosis lateral amiotrófica: mortalidad y complicaciones.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that causes severe dysphagia and weight loss. Percutaneous endoscopic gastrostomy (PEG) is currently the technique of choice for the enteral nutrition of these patients. OBJECTIVES: To analyse mortality and complications in a series of patients diagnosed with ALS who underwent PEG, and to evaluate factors related to patient survival after the procedure. MATERIAL AND METHODS: We performed a prospective, observational study including all patients diagnosed with ALS and treated by our hospital's Gastroenterology Department in the period 1997-2013. We studied mortality, complications, and clinical and biochemical parameters, and correlated these with the survival rate. RESULTS: The study included a total of 57 patients, of whom 49 were ultimately treated with PEG. ALS onset was bulbar in 30 patients and spinal in 19. Mortality during the procedure and at 30 days was 2% (n = 1). Six patients (12.2%) experienced major complications; 17 (34.7%) experienced less serious complications which were easily resolved with conservative treatment. No significant differences were observed in forced vital capacity, albumin level, or age between patients with (n = 6) and without (n = 43) major complications. CONCLUSIONS: PEG is an effective, relatively safe procedure for the enteral nutrition of patients with ALS, although not without morbidity and mortality. Neither forced vital capacity nor the form of presentation of ALS were associated with morbidity in PEG.

Phase II trial of intravenous endotoxin in patients with colorectal and non-small cell lung cancer.

We report the immunological and clinical results of a phase II trial with intravenously administered highly purified endotoxin (Salmonella abortus equi) in patients with advanced cancer. 15 patients with non-small cell lung cancer and 27 with colorectal cancer were entered into the study. 37 evaluable patients received at least four injections of endotoxin (4 ng/kg body weight) and 1600 mg ibuprofen orally in 2-week intervals. Transient renal (WHO grade 0-1) and hepatic (WHO grade 0-4) toxicities occurred in several patients. Constitutional side-effects such as fever, chills and hypotension could not be prevented completely by pretreatment with ibuprofen. 3 patients in the colorectal cancer group demonstrated objective responses (1 complete remission (CR), 2 partial remission (PR)). The complete remission has been maintained for more than 3 years, while the partial remissions were stable for 7 and 8 months, respectively. Only marginal antitumour effects were seen in the lung cancer group. Tolerance of the macrophage system to the stimulatory effect of endotoxin, as measured by human necrosis factor alpha (TNF-alpha) release into serum, built up after the first administration and remained at a steady-state level after each subsequent injection. In constrast, rising CD4:CD8 ratio and release of tumour necrosis factor beta (TNF-beta) indicated the continuing activation of the lymphocyte system by repetitive injections of endotoxin.

[Prolonged muscle weakness associated with the administration of non-depolarizing neuromuscular blocking agents in critically ill patients]. / Debilidad muscular prolongada asociada a la administración de bloqueadores neuromusculares no despolarizantes en el paciente crítico.

Generalized muscle weakness is a common disorder in patients undergoing mechanical ventilation. The cause is unknown but is attributed to the administration of non-depolarizing neuromuscular blocking and other drugs, mainly steroids, or to the presence of sepsis or multiorgan failure. Specific clinical pictures (polyneuropathy, myopathy and prolonged muscle weakness) develop in function of the underlying cause, although etiological factors may sometimes interact. Differential diagnosis is carried out with the aid of electromyography and pathology of the peripheral muscle. Costs are high and prognosis is uncertain. Completeness of neuromuscular blockade must be monitored in these patients to guide the administration of drugs, to avoid overdoses, to maintain muscle activity and to detect a chain of reactions among concomitant medications or pathophysiologic changes.

[Electromyographic response to precurarization with vecuronium bromide]. / Respuesta electromiográfica de la precurarización con bromuro de vecuronio.

OBJECTIVE: To analyze electromyographic response and clinical effects after precurarization with vecuronium bromide (0.01 mg/Kg), also noting intubation conditions and the presence or not of fasciculations after administration of succinylcholine (1.5 mg/Kg). PATIENTS AND METHODS: A single precurarization dose of vecuronium was administered to 20 patients 5 minutes before anesthetic induction for general surgery. During this period we monitored neuromuscular transmission of the cubital nerve in the wrist by electromyography with a series of 4 stimuli, expressing each as the percentage of the first response and of the ratio T4/T1. We also recorded clinical repercussions. General anesthesia was then induced; after administration of succinylcholine, the presence or not of fasciculations was noted and intubation conditions were evaluated. RESULTS: The electromyographic response after precurarization was highly variable, as 4 different responses were recorded. We found potentiation phenomena in 20% of our patients, diminished response in 60%, fatigue phenomena in 15% and no change in 5%. Clinical signs noted were blurred vision and heavy eyelids. Fasciculations disappeared in 95% of the patients and intubation conditions were excellent. CONCLUSIONS: Vecuronium at a precurarization dose produces highly varied but well-tolerated electromyographic responses. The drug is effective in eliminating fasciculations produced by succinylcholine and does not affect intubation conditions.

La gastrostomía endoscópica percutánea en pacientes diagnosticados de esclerosis lateral amiotrófica: mortalidad y complicaciones / Percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis: Mortality and complications

INTRODUCCIÓN: La esclerosis lateral amiotrófica (ELA) es una enfermedad neurodegenerativa que produce disfagia grave y pérdida de peso. La gastrostomía endoscópica percutánea (GEP) es en la actualidad la técnica de elección para la nutrición enteral de estos pacientes. OBJETIVOS: Analizar la mortalidad y las complicaciones en una serie de pacientes diagnosticados de ELA a los que se realizó la GEP y evaluar los factores relacionados con la supervivencia después del procedimiento. MATERIAL Y MÉTODOS: Estudio observacional prospectivo en el que se incluyeron los pacientes diagnosticados de ELA atendidos en el Servicio de Gastroenterología (años 1997-2013) a los que se realizó GEP. Se estudiaron la mortalidad, las complicaciones y los parámetros clínicos y analíticos, correlacionándolos con la tasa de supervivencia. RESULTADOS: Se incluyeron 57 pacientes, de los que finalmente se pudo realizar la GEP en 49. La ELA fue de inicio bulbar en 30 y espinal en 19. La mortalidad durante el procedimiento y a los 30 días fue del 2% (n = 1). Se registraron complicaciones mayores en 6 pacientes (12,2%) y complicaciones de menor gravedad, que se resolvieron fácilmente con tratamiento conservador, en 17 (34,7%). No se observaron diferencias en la capacidad vital forzada, la cifra de albúmina o la edad entre los pacientes con (n = 6) o sin (n = 43) complicaciones mayores. CONCLUSIONES: La GEP en los pacientes con ELA es un procedimiento eficaz y relativamente seguro para la nutrición enteral de estos pacientes, aunque no exento de morbimortalidad. Ni la capacidad vital forzada ni la forma de inicio de la enfermedad fueron factores asociados a morbilidad en la GEP

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that causes severe dysphagia and weight loss. Percutaneous endoscopic gastrostomy (PEG) is currently the technique of choice for the enteral nutrition of these patients. OBJECTIVES: To analyse mortality and complications in a series of patients diagnosed with ALS who underwent PEG, and to evaluate factors related to patient survival after the procedure. MATERIAL AND METHODS: We performed a prospective, observational study including all patients diagnosed with ALS and treated by our hospital's Gastroenterology Department in the period 1997-2013. We studied mortality, complications, and clinical and biochemical parameters, and correlated these with the survival rate. RESULTS: The study included a total of 57 patients, of whom 49 were ultimately treated with PEG. ALS onset was bulbar in 30 patients and spinal in 19. Mortality during the procedure and at 30 days was 2% (n = 1). Six patients (12.2%) experienced major complications; 17 (34.7%) experienced less serious complications which were easily resolved with conservative treatment. No significant differences were observed in forced vital capacity, albumin level, or age between patients with (n = 6) and without (n = 43) major complications. CONCLUSIONS: PEG is an effective, relatively safe procedure for the enteral nutrition of patients with ALS, although not without morbidity and mortality. Neither forced vital capacity nor the form of presentation of ALS were associated with morbidity in PEG

Downregulation of the proinflammatory cytokine response to endotoxin by pretreatment with the nontoxic lipid A analog SDZ MRL 953 in cancer patients.

Interfering with the endotoxin-mediated cytokine cascade is thought to be a promising approach to prevent septic complications in gram-negative infections. The synthetic lipid A analog SDZ MRL 953 has been shown to be protective against endotoxic shock and bacterial infection in preclinical in vivo models. As part of a trial of unspecific immunostimulation in cancer patients, we conducted a double-blind, randomized, vehicle-controlled phase I trial of SDZ MRL 953 to investigate, first, its biologic effects and safety of administration in humans and, second, its influence on reactions to a subsequent challenge of endotoxin (Salmonella abortus equi). Twenty patients were treated intravenously with escalating doses of SDZ MRL 953 or vehicle control, followed by an intravenous application of endotoxin (2 ng/kg of body weight [BW]). Administration of SDZ MRL 953 was safe and well-tolerated. SDZ MRL 953 itself increased granulocyte counts and serum levels of granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6), but not of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha), IL-1beta, and IL-8. Compared with vehicle control, pretreatment with SDZ MRL 953 markedly reduced the release of TNF-alpha, IL-1beta, IL-8, IL-6, and G-CSF, but augmented the increase in granulocyte counts to endotoxin. Induction of tolerance to the endotoxin-mediated cascade of proinflammatory cytokines by pretreatment with SDZ MRL 953 in patients at risk may help to prevent complications of gram-negative sepsis.

Bloqueo nervioso en el tratamiento del dolor postoperatorio de pacientes intervenidos de hernia inguinal o crural en una unidad de CMA / Nerve block for postoperative pain relief after inguinal or femoral hernia repair in an ambulatory surgical unit

OBJETIVO: E éxito de un programa de Cirugía Mayor Ambulatoria depende en gran medida de un correcto tratamiento del dolor postoperatorio. Nuestro objetivo es presentar los resultados obtenidos con el bloqueo nervioso. MATERIAL Y MÉTODOS: Estudio restrospectivo. Se utiliza la anestesia general con mascarilla laringea combinada con la infiltración local de ropivacaína. La analgesia se completa con Metamizol magnésico. Se evalúa el dolor mediante una escala numérica visual y de forma indirecta, la asistencia a urgencias, el estado emocional al regresar al domicilio,e l grado de satisfacción con el tratamiento y el grado de recomendación de nuestra unidad. RESULTADOS: Se han intervenido 167 enfermos, 158 hombres y 9 mujeres. Edad media 50,6 años. Corresponden a hernias inguinales 155, crurales 7, inguinal mas crural 3, recidivas 2. Técnicas: Gilbert 21, Lichtenstein 38, Rutkow-Robbins 57, Hernioplastia PHS 44, Lichtenstein crural 7. La valoración del dolor fue: Grado 0: 7%, 1: 19,7%, 2: 12,2%, 3: 22,5%, 4: 12,6%,: 11,2%, 6: 5,6%, 7: 4,2%, 8: 4,2%. El 97,1% no necesitó tomar más calmantes. Solo un enfermo necesitó acudir a urgencias por un hematoma. El 95% estuvo tranquilo al alta. El 54,9% se mostraron satisfechos y el 40,8 muy satisfechos con el tratamiento. El 52,!!% no dudarían en recomendar nuestrao programa. Ningún enfermo telefoneó por dolor. Complicaciones: 2 (1,1%) bloqueos del nervio femorocutáneo y 5 (2,9%) del obturador. Representaron 4 (2,3%) ingresos (AU)

OBJECTIVES: The success of a program for ambulatory surgery depends on the correct management of postoperative pain. The objective of this article is to present our results in the use of nerve blocks. MATERIAL AND METHOD: A restrospective study. The general anaesthesia procedure included laryngeal mask and ropivacaine local infiltration. Postoperative anaesthesia was combined with metamizol. Pain was evaluated by a visual numeric scale from 0 (no pain) to 10 (maximum pain). Other stats were evaluated: Emergency attendance required, emotional aspects on reaching home, satisfaction with medical care and if they would recommended our units as a surgical centre to other patients. RESULTS: 167 patients underwent surgery, 158 men and 9 women. Mean age was 50,6 years. We found 71 right inguinal hernias, 84 left inguinal hernias, 7 femoral hernias, 3 right inguinal and femoral combined hernias and 2 right inguinal recurrent hernias. Surgical techniques used for the repair were: Gilbert´s technique, 21; Lichtenstein inguinal hernia repair, 38; Rutkow-Robbins technique, 57; PHS hernioplaty, 44: Lechtenstein´s femoral hernia repair, 7. The analogical pain evaluation scale results were: grade 0: 7%, grade 1: 19,7%, grade 3: 22,5%, grade 4: 12,6%, grade 5: 11,2%, grade 6: 5,6%, grade 7: 4,2%, grade 8: 4,2%. No supplementary post-operative analgesia was required in 97,1% of the patients. Just one required emergency assistance due to a haematoma. Almost 95% of the patients stayed calm at home. 54% were satisfied and 40,8% were highly satisfied with the surgical results. Regarding recommending our surgical program: 52,11% had no doubt about it. No phone calls were received due to pain. The complications were 2 femoro-cutaneous nerve (1,1%) and 5 obturator (2,9%) blocks. Just 4 of the cases required hospital admission (2,3%). DISCUSSION: The postoperative anaesthesia and grade of comfort obtained with this procedure highly satisfactory. There was no hospital admission due to pain (AU)

Debilidad muscular prolongada asociada a la administración de bloqueadores neuromusculares no despolarizantes en el paciente crítico / Prolonged muscle weakness with the administration of non-depolarizing neuromuscular blocking agents in critical care patients

La debilidad muscular generalizada es un cuadro común en aquellos pacientes sometidos a ventilación mecánica. La causa es desconocida, pero se relaciona con la administración de bloqueadores neuromusculares no despolarizantes y otros fármacos, fundamentalmente los esteroides, así como con la presencia de enfermedad clínica relacionada con sepsis o fallo multiorgánico. Existen cuadros específicos (polineuropatía, miopatía y debilidad muscular prolongada) que se desarrollan en un sentido u otro, dependiendo de la posible causa etiológica, si bien pueden existir interacciones entre ellos. El diagnóstico diferencial se realiza mediante el estudio electromiográfico y anatomopatológico de un músculo periférico. La aparición de estos cuadros provoca un coste elevado y un pronóstico incierto en los pacientes que lo padecen. En estos pacientes, se precisa una monitorización de la intensidad del bloqueo como guía de la administración de los bloqueadores neuromusculares, para evitar una sobredosificación, mantener una actividad muscular y detectar las interferencias desencadenadas por la medicación concomitante o los cambios fisiopatológicos (AU)

No disponible