Prophylactic Activated Recombinant Factor VII in Liver Resection and Liver Transplantation: Systematic Review and Meta-Analysis

Intraoperative blood loss is a frequent complication of hepatic resection and orthotopic liver transplantation. Recombinant activated coagulation factor VII (rFVIIa) is a coagulation protein that induces hemostasis by directly activating factor X. There is no clear information about the prophylactic value of rFVIIa in hepatobiliary surgery, specifically in liver resection and orthotopic liver transplantation. The aim of this study was to assess the effect of rFVIIa prophylaxis to prevent mortality and bleeding resulting from hepatobiliary surgery.Relevant randomized trials were identified by searching The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index. Randomized clinical trials comparing different rFVIIa prophylactic schemas against placebo or no intervention to prevent bleeding in hepatobiliary surgery were included. Adults undergoing liver resection, partial hepatectomy, or orthotopic liver transplantation were included. Dichotomous data were analyzed calculating odds ratios (ORs) and 95% confidence intervals (CIs). Continuous data were analyzed calculating mean differences (MD) and 95% CIs.Four randomized controlled trials were included. There were no significant differences between rFVIIa and placebo for mortality (OR 0.96; 95% CI 0.35-2.62), red blood cell units (MD 0.32; 95% CI -0.08-0.72) or adverse events (OR 1.55; 95% CI 0.97-2.49).The available information is limited, precluding the ability to draw conclusions regarding bleeding prophylaxis in hepatobiliary surgery using rFVIIa. Although an apparent lack of effect was observed in all outcomes studied, further research is needed

Experiencia en el manejo de pacientes graves con COVID-19 en una unidad de terapia intensiva

Objetivo: Describir las características clínicas y el manejo de pacientes graves con COVID-19. Método: Estudio observacional, descriptivo, longitudinal y restrospectivo. Resultados: Ingresaron 56 pacientes, el 80.3% (n = 45) de sexo masculino, con un promedio de edad de 58 [46-67] años. Las principales condiciones de comorbilidad fueron obesidad, hipertensión y diabetes. El tiempo de inicio de los síntomas al ingreso fue de 9 [7-14] días, siendo los más frecuentes disnea, fiebre y tos seca. Los datos de laboratorio fueron linfopenia y elevación de deshidrogenasa láctica, fibrinógeno, dímero D, ferritina y proteína C reactiva. El 100% de los pacientes requirieron ventilación mecánica, con una mediana de tiempo de ventilación de 12 [6-17] días, y el 66% (n = 37) requirieron posición en prono. El tratamiento farmacólogico fue a base de azitromicina, hidroxicloroquina, tocilizumab y esteroides, principalmente. Las complicaciones más frecuentes fueron lesión renal aguda, enfermedad tromboembólica venosa e infarto agudo al miocardio. La tasa de mortalidad fue del 17.8% (n = 10). Conclusión: Los pacientes graves en nuestro hospital fueron en su mayoría personas de la tercera edad y con obesidad, siendo las variables de mayor puntaje SOFA y lesión renal aguda las asociadas con mayor mortalidad

Levosimendan: Nueva estrategia en el manejo de la falla cardíaca

La insuficiencia cardíaca congestiva se ha considerado como un grave problema de salud. De manera tradicional, la insuficiencia cardíaca ha sido manejada con diferentes fármacos, como son los diuréticos, digital, inotrópicos del tipo de las catecolaminas y no catecolaminas; sin embargo, el manejo de los mismos, también tienen efectos secundarios en donde se incluyen la génesis de las arritmias e incluso la muerte. Un nuevo grupo de drogas recientemente ha impactado en el manejo de los pacientes con insuficiencia cardíaca aguda y crónica, estos son los sensibilizadores de calcio, que actúan incrementando la contractilidad miocárdica, sin aumentar la liberación del calcio citosólico. El levosimendan, es un sensibilizador de calcio que además de aumentar la contractilidad, posee efecto vasodilatador por activación de los canales de K(ATP), siendo ambos mecanismos los que ofrecen una opción terapéutica en la falla cardíaca. Varios estudios han comprobado la eficacia y seguridad de la droga en diferentes estadios y poblaciones, por lo que se considera en la actualidad que el uso del levosimendan es una alternativa real y segura de tratamiento en aquellos pacientes con falla ventricular aguda o crónica que necesiten soporte farmacológico endovenos

Impacto del balón intra-aórtico de contrapulsación en la mortalidad por choque cardiogénico secundario a infarto agudo del miocardio

Propósito del trabajo: Determinar el impacto del balón intra-aórtico de contrapulsación en la mortalidad por choque cardiogénico postinfarto agudo del miocardio. Método: 292 pacientes con infarto agudo del miocardio ingresaron a la unidad de cuidados intensivos coronarios en el período comprendido de febrero de 2001 a febrero del 2003, de los cuales 40 cumplieron los criterios de inclusión y exclusión, posteriormente fueron divididos en 2 grupos: choque cardiogénico temprano y tardío, se les asignó al azar y de forma ciega a recibir tratamiento a base de inotrópicos aislados e inotrópicos más balón intra-aórtico de contrapulsación. Resultados: Se observaron diferencias significativas en ambos grupos en los valores de la presión en cuña de la pulmonar (20.4 ± 1.6 vs 24.4 ± 1.50, p = 0.0004) y el índice cardíaco (2.06 ± 0.7 vs 1.65 ± 0.18, p = 0.0002). El grupo de choque tardío presentó una mayor mortalidad (25.9% vs 61.5%, p < 0.05), los pacientes que recibieron apoyo con balón mostraron una disminución en la mortalidad del 66% y 69% en choque temprano y tardío respectivamente. Conclusiones: El uso del balón intra-aórtico de contrapulsación en los pacientes que desarrollan choque cardiogénico post IAM disminuye la mortalidad, como coadyuvante con el uso de inotrópicos y angioplastía primaria

Usefulness of qSOFA and ECOG Scores for Predicting Hospital Mortality in Postsurgical Cancer Patients without Infection

Background. The quick sequential organ failure assessment (qSOFA) and the Eastern Cooperative Oncologic Group (ECOG) scale are simple and easy parameters to measure because they do not require laboratory tests. The objective of this study was to compare the discriminatory capacity of the qSOFA and ECOG to predict hospital mortality in postsurgical cancer patients without infection. Methods. During the period 2013–2017, we prospectively collected data of all patients without infection who were admitted to the ICU during the postoperative period, except those who stayed in the ICU for <24 hours or patients under 18 years. The ECOG score during the last month before hospitalization and the qSOFA performed during the first hour after admission to the intensive care unit (ICU) were collected. The primary outcome for this study was the in-hospital mortality rate. Results. A total of 315 patients were included. The ICU and hospital mortality rates were 6% and 9.2%, respectively. No difference was observed between the qSOFA [AUC=0.75 (95% CI = 0.69-0.79)] and the ECOG scores [AUC=0.68 (95%CI =0.62-0.73)] (p=0.221) for predicting in-hospital mortality. qSOFA greater than 1 predicted in-hospital mortality with a high sensitivity (100%) but low specificity (38.8%); positive predictive value of 26.3% and negative predictive value of 93.1% compared to 74.4% of specificity, 55.1% of sensitivity%; positive predictive value of 18% and negative predictive value of 94.2% for an ECOG score greater than 1. Multivariable Cox regression analysis identified two independent predicting factors of in-hospital mortality, which included ECOG score during the last month before hospitalization (HR: 1.46; 95 % CI: 1.06-2.00); qSOFA calculated in the first hours after ICU admission (OR: 3.17; 95 % CI: 1.79–5.63). Conclusion. No difference was observed between the qSOFA and ECOG for predicting in-hospital mortality. The qSOFA score performed during the first hour after admission to the ICU and ECOG scale during the last month before hospitalization were associated with in-hospital mortality in postsurgical cancer patients without infection. The qSOFA and ECOG score have a potential to be included as early warning tools for hospitalized postsurgical cancer patients without infection

Outcome of Critically Ill Patients with Testicular Cancer

Purpose. To evaluate the clinical characteristics and outcomes of critically ill patients with testicular cancer (TC) admitted to an oncological intensive care unit (ICU). Methods. This was a prospective observational study. There were no interventions. Results. During the study period, 1,402 patients with TC were admitted to the Department of Oncology, and 60 patients (4.3%) were admitted to the ICU. The most common histologic type was nonseminomatous germ cell tumors (55/91.7%). The ICU, hospital, and 6-month mortality rates were 38.3%, 45%, and 63.3%, respectively. The Cox multivariate analysis identified the white blood cells count (HR = 1.06, 95% CI = 1.01–1.11, and P=0.005), ionized calcium (iCa) level (HR = 1.23, 95% CI = 1.01–1.50, and P=0.037), and 2 or more organ failures during the first 24 hours after ICU admission (HR = 3.86, 95% CI = 1.96–7.59, and P<0.001) as independent predictors of death for up to 6 months. Conclusion. The ICU, hospital, and 6-month mortality rates were 38.3%, 45%, and 63.3%, respectively. The factors associated with an increased 6-month mortality rate were white blood cells count, iCa level, and 2 or more organ failures during the first 24 hours after ICU admission