Temporary internal pacing.

Technology and insertion techniques for cardiac temporary internal pacing have experienced a remarkable development over the last few years. Despite this fact, the procedure continues to have potentially fatal associated complications. Temporary internal pacing is indicated for the treatment of bradyarrhythmias or tachyarrhythmias refractory to conventional treatment, or arrhythmias causing cardiovascular or clinical instability of the patient. On the other hand, the indications of temporary cardiac pacing are far less well defined than those of permanent pacing. Since the decision of implementing temporary pacing is complex and delicate, it should always be carefully considered, and over-indication should be avoided. We must base these decisions on robust knowledge of the arrhythmias that may benefit from temporary internal pacing, and should also acquire the habit of considering external temporary pacing among other less aggressive treatments, and to make the best use of new technologies such as echocardiography that add accuracy to the procedure.

[Boussignac CPAP in diagnostic-therapeutic procedures in the critical patient]. / CPAP de Boussignac en procedimientos diagnóstico-terapéuticos en pacientes críticos.

Boussignac valve is a new resource to consider in acute pulmonary edema cardiogenic management. As it generates positive airways pressure continuous (CPAP) and it is very simple to use, its use is being extended to emergency, urgency and hospitalization ward services. This valve is a small tube placed over the interface expiratory port. The gas flow (oxygen/air) accelerates when it crosses through four microchannels in the valve wall, pressurizing the bronchial tree by the principle of the energy in movement. It has a functioning, not hermetic system, allowing the passage of a catheter through it to help the patient (to drink, to eat, to aspirate, etc.). These characteristics make it possible to extend it use in those patients who, in extreme conditions, need diagnostic tests that could deteriorate their respiratory situation, such as endoscopy procedures. We report three critical patients who received CPAP with a Boussignac valve connected to an orofacial interface, while performing two fibrobronchoscopies and one upper digestive tract endoscopy. All finished successfully and none of them need orotracheal intubation.

[Role of daptomycin in the empirical and directed therapy of infections caused by Gram-positive bacteria in the critically ill patient]. / Papel de daptomicina en el tratamiento empírico y dirigido de infecciones por cocos grampositivos del paciente crítico.

Infections caused by Gram-positive bacteria are a serious problem and is associated with high mortality. Among them, we should highlight those caused by methicillin-resistant Staphylococcus aureus (MRSA). Primary bacteremia, catheter-related bloodstream infections and constitute the main presentations. Vancomycin has traditionally been the treatment of choice for these infections, but its activity is not satisfactory especially in cases of MRSA with minimum inhibitory concentration (MIC) > 1 mg/L. Daptomycin is a lipopeptide antibiotic active against Gram-positive bacteria including MRSA and glycopeptide-resistant Enterococcus spp.It is worth mentioning that daptomycin is rapidly bactericidal against methicillin-sensitive S. aureus, more potent than vancomycin and at least as active as isoxazole penicillins. This article discusses the role of this antibiotic in the empirical treatment of infections and directed by Gram-positive bacteria affecting critically ill patients.

[Management of the pulmonary secretions in the critical patient]. / Manejo de las secreciones pulmonares en el paciente crítico.

Pulmonary complications in critical patient, derived from the baseline disease, immobility and nosocomial infections, are one of the major problems in their management. Respiratory physiotherapy programs help to solve some of these problems. However, the available evidence is scarce both critical patients and chronic out-patients. In recent years, the physiotherapy techniques applied in chronic patients are being used in critical patients, improving oxygenation, compliance and aspiration of secretions, although without effects on mean stay and mortality. This article reviews the recommendations of the scientific societies related with physiotherapy in critical patients and presents the different techniques.

[Methodology in non-invasive ventilation]. / Metodología en ventilación no invasiva.

Objective during the application of noninvasive ventilation (NIV) in acute respiratory failure is, as occurs in conventional mechanical ventilation, to improve gas exchange. Expiratory pressure is applied to favour recruitment of collapsed alveoli, improving oxygenation. Inspiratory pressure use on airway aids respiratory muscle rest and decrease respiratory work, which has a direct repercussion in decreasing oxygen consumption. The NIV preserves defence mechanisms of the patients airway intact, which noticeably decreases appearance of mechanical ventilation associated pneumonia, with subsequent benefit in health care cost, stay and morbidity-mortality. We have reviewed the literature available regarding respiratory modes used in NIV, patient monitoring, humidification, and inhaled drug administration. However, the benefits of NIV are obtained when success of the technique is reached; this is depending on patients' collaboration, adequate indication, underlying disease, material resources available, and mainly, training and dedication of the personnel applying the respiratory support.

[Non-invasive ventilation in the Intensive Care Units. Part I: background and interphase]. / Ventilación no invasiva en las Unidades de Cuidados Intensivos. Parte I: fundamentos e interfase.

INTRODUCTION: Non-invasive ventilation is a respiratory support method that has gained ground in the management of patients with acute respiratory failure. Currently, it has become a first line instrument in the treatment of respiratory failure of the critical patient. Scientific evidence supports its use in patients with acute lung edema, acute hypercapnic respiratory failure, immunosuppressed patients and patients with atelectasis. The objectives of this review are 1, introduce the reader to the non-invasive ventilation; 2, inform on the basics of its use in critical patients; and 3, the management of the interphase in acute situations. To do so, the bibliography available on it in databases (Medline and Cochrane) and published textbooks were used. CONCLUSIONS: The characteristics of the technique require careful dedication of the health care personnel, with adequate knowledge about the technology involved in addition to the collaboration of the patients to make it successful.

Right bundle branch block-induced Q waves simulating anterior myocardial infarction extension.

A concept generally accepted in clinical electrocardiography is the assumption that a right bundle branch block (RBBB) does not alter significantly the initial portion of the QRS complex and because the left bundle branch is intact, the septum is activated normally in a left-to-right direction. We report a woman with an acute anterior myocardial infarction (MI) in which a small R wave was present in leads V1 and V4, but with the development of RBBB associated with PR-interval prolongation, these R waves were replaced by Q waves. Subsequently, the electrocardiographic features of anterior MI disappeared concomitantly with the loss of RBBB. The clinical and electrophysiologic implications of these findings are discussed.