Síndrome compartimental abdominal en el paciente crítico con patología médica

Estudi observacional de 60 pacients ingressats a la UCI per patologia extraabdominal, que demostra alta incidència de HIA (90%) i que el valor de PIA màxima és marcador pronòstic del SCA però no prediu mortalitat. Els graus més elevats d'HIA s'associen amb VMI, shock, SDRA, insuficiència renal e ili. La PIA màxima del pacient crític no neurològic (sèptic, traumatològic i respiratori) és més elevada que la del no neurològic, 20 i 16 mmHg respectivament. El valor de PIA màxima que millor prediu insuficiència renal al pacient no neurològic és 18,5mmHg. La PIA màxima es correlaciona amb l'estada a UCI i hospitalària.Estudio observacional de 60 pacientes ingresados en UCI por patología extraabdominal, que demuestra alta incidencia de HIA (90%) y que el valor de PIA máxima es marcador pronóstico del SCA pero no predice mortalidad. Los grados más elevados de HIA se asociaron con VMI, shock, SDRA, insuficiencia renal e íleo. La PIA máxima del paciente crítico no neurológico (séptico, traumatológico y respiratorio) es mayor que la del no neurológico, 20 y 16 mmHg respectivamente. El valor de PIA máximo que mejor predice insuficiencia renal en el paciente no neurológico es 18,5mmHg. La PIA máxima se correlaciona con estancia en UCI y hospitalaria

Related Factors of Anemia in Critically Ill Patients: A Prospective Multicenter Study

Anemia; Blood; Practice managementAnemia; Sangre; Gestión prácticaAnèmia; Sang; Gestió pràcticaAnemia is common in critically ill patients; almost 95% of patients admitted to intensive care units (ICUs) have hemoglobin levels below normal. Several causes may explain this phenomenon as well as the tendency to transfuse patients without adequate cause: due to a lack of adherence to protocols, lack of supervision, incomplete transfusion request forms, or a lack of knowledge about the indications, risks, and costs of transfusions. Daily sampling to monitor the coagulation parameters and the acid–base balance can aggravate anemia as the main iatrogenic factor in its production. We studied the association and importance of iatrogenic blood loss and other factors in the incidence of anemia in ICUs. We performed a prospective, observational, multicenter study in five Spanish hospitals. A total of 142 patients with a median age of 58 years (IQI: 48–69), 71.83% male and 28.17% female, were admitted to ICUs without a diagnosis of iatrogenic anemia. During their ICU stay, anemia appeared in 66.90% of the sample, 95 patients, (95% CI: 58.51–74.56%). Risk factors associated with the occurrence of iatrogenic anemia were arterial catheter insertion (72.63% vs. 46.81%, p-value = 0.003), venous catheter insertion (87.37% vs. 72.34%, p-value = 0.023), drainages (33.68% vs. 12. 77%, p-value = 0.038), and ICU stay, where the longer the stay, the higher the rate of iatrogenic anemia (p-value < 0.001). We concluded that there was a statistical significance in the production of iatrogenic anemia due to the daily sampling for laboratory monitoring and critical procedures in intensive care units. The implementation of patient blood management programs could address these issues

“COAGULATION”: a mnemonic device for treating coagulation disorders following traumatic brain injury—a narrative-based method in the intensive care unit

IntroductionCoagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication.MethodsA narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device.Results and conclusionEleven factors were identified: cerebral computed tomography, oral anticoagulant &amp;amp; antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid–base status, forming the acronym “Coagulation.” This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis

Related Factors of Anemia in Critically Ill Patients : A Prospective Multicenter Study

Anemia is common in critically ill patients; almost 95% of patients admitted to intensive care units (ICUs) have hemoglobin levels below normal. Several causes may explain this phenomenon as well as the tendency to transfuse patients without adequate cause: due to a lack of adherence to protocols, lack of supervision, incomplete transfusion request forms, or a lack of knowledge about the indications, risks, and costs of transfusions. Daily sampling to monitor the coagulation parameters and the acid-base balance can aggravate anemia as the main iatrogenic factor in its production. We studied the association and importance of iatrogenic blood loss and other factors in the incidence of anemia in ICUs. We performed a prospective, observational, multicenter study in five Spanish hospitals. A total of 142 patients with a median age of 58 years (IQI: 48-69), 71.83% male and 28.17% female, were admitted to ICUs without a diagnosis of iatrogenic anemia. During their ICU stay, anemia appeared in 66.90% of the sample, 95 patients, (95% CI: 58.51-74.56%). Risk factors associated with the occurrence of iatrogenic anemia were arterial catheter insertion (72.63% vs. 46.81%, p -value = 0.003), venous catheter insertion (87.37% vs. 72.34%, p -value = 0.023), drainages (33.68% vs. 12. 77%, p -value = 0.038), and ICU stay, where the longer the stay, the higher the rate of iatrogenic anemia (p -value < 0.001). We concluded that there was a statistical significance in the production of iatrogenic anemia due to the daily sampling for laboratory monitoring and critical procedures in intensive care units. The implementation of patient blood management programs could address these issue

“COAGULATION”: a mnemonic device for treating coagulation disorders following traumatic brain injury—a narrative-based method in the intensive care unit

IntroductionCoagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication.MethodsA narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device.Results and conclusionEleven factors were identified: cerebral computed tomography, oral anticoagulant &amp; antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid–base status, forming the acronym “Coagulation.” This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

INNOVA Research Journal

El presente trabajo tiene por objetivo determinar la importancia del Órgano de Solución de Diferencias de la OMC dentro de las negociaciones sobre el acceso a los mercados internacionales. El área que se está investigando es el funcionamiento de la OMC especialmente, cómo esta resuelve las diferencias entre países, especialmente teniendo en cuenta el análisis de costo-beneficio que se incurre. La investigación se lleva a cabo a través de la revisión de fuentes primarias y secundarias con un enfoque cualitativo y comparativo así como perspectiva analítica y descriptiva. El resultado que se obtuvo después de estudiar dos casos específicamente en Ecuador, nos muestra cómo el organismo proporciona buenas oportunidades de desarrollo comercial a nivel mundial con ahorro de recursos. Se recomienda que los países hagan conciencia y permitan que estos organismos les asesoren al momento de tomar decisiones y resolver conflictos en búsqueda de un comercio más eficaz y eficiente

Síndrome compartimental abdominal en el paciente crítico con abdomen agudo y pancreatitis aguda grave

La presión intraabdominal (PIA) es la presión dentro de la cavidad abdominal. El aumento de la misma o hipertensión intraabdominal (HIA) es ya conocida desde hace más de un siglo y se sabe que puede provocar alteraciones en la funcionalidad del organismo. En el año 1876 se relacionó el aumento de la PIA con la disfunción renal. Desde entonces y, sobretodo, durante la última década, han sido innumerables las referencias bibliográficas sobre la misma, su forma de medida y sus consecuencias. Así, en el año 2006 se definió, por una comisión de expertos, el síndrome compartimental abdominal (SCA) como aquella PIA &#8805; 20 mmHg, mantenida y asociada a nueva o nuevas disfunciones orgánicas. A pesar de dicha comisión, siguen planteándose muchas preguntas sobre el método de determinación de la PIA y sobre qué medida de la misma considerar relevante en la evolución del paciente crítico, así como sus consecuencias clínicas.El presente trabajo estudia el valor de la PIA en dos tipos de pacientes críticos: en la pancreatitis aguda grave (grado E de Balthazar) y en el paciente postoperado de cirugía abdominal urgente.Los objetivos planteados son novedosos y útiles para la práctica clínica diaria. Dichos objetivos son mayoritariamente comunes a ambos grupos de pacientes:1. Validación del método de determinación de la PIA con 50 mL de solución salina isotónica. 2. Validación del peor valor de PIA como la presión adecuada para realizar los estudios sobre SCA.3. Comparar la PIA con otros factores pronósticos: APACHE II y PCR. 4. Demostrar que la PIA es marcador pronóstico del SCA y de mortalidad.5. Establecer un valor de PIA pronóstico del SCA y de mortalidad.6. Demostrar que la PIA es útil en la toma de decisiones terapéuticas y establecer un valor de PIA que determine un cambio en el tratamiento.7. Demostrar que la PIA se relaciona con la estancia hospitalaria.8. Establecer los factores pronósticos de mortalidad en esta patología.9. Comparar la PIA de la pancreatitis aguda grave en función de si la etiología es biliar o enólica y en función de la presencia o no de necrosis.Dentro de las aportaciones derivadas de este trabajo destaca la validación de la determinación de la PIA intravesical con 50 mL de solución salina isotónica, establece como valor de PIA relevante en la práctica clínica diaria el peor valor de PIA a lo largo de la evolución de los pacientes, asocia el incremento de la PIA con la disfunción multiorgánica y la mortalidad y, establece un punto de corte diferente para cada grupo de pacientes a partir del cual se prevee el desarrollo de fallo orgánico y de muerte. También sugiere que la PIA es útil para optimizar el tratamiento médico y para ayudar en la toma de decisiones quirúrgicas.The intraabdominal pressure (IAP) is the pressure inside the abdomen. The increase in the abdominal pressure or intraabdominal hypertension (IAH) is well known since the nineteen century and is associated with multiple organ dysfunction. In the 1876 the IAH was related to renal dysfunction. Since then and specially during the last century, many studies were published about the abdominal compartment syndrome (ACS) and how to measure it. That's why an expert committee was created in 2004 and the first consensus about the ACS was published in 2006. The ACS was defined as sustained IAP > 20 mmHg associated with one o more new organ dysfunction. Despite this consensus there are still many controversial points such as which is the critical IAP that causes several organ dysfunction in the different critical patients. This work studies the predictive value of two types of critical patients: severe acute pancreatitis (grade E of Balthazar's classification) and patients after an abdominal surgery because of acute abdomen. The objectives studied are of great utility for the daily clinical practice. These objectives are common for both group of patients: 1. Validation of the IAP determination with 50 mL of isotonic saline solution. 2. Validation of the worse IAP as the best pressure to study the ACS. 3. Compare the IAP with other prognostic factors: APACHE II and reactive C protein. 4. To prove that IAP is a marker of the ACS and predictor of mortality. 5. To establish an IAP value to predict the ACS and mortality. 6. To prove that IAP is of great utility to make therapeutic decisions and to establish an IAP value that make change the treatment. 7. To prove the relation between the IAP and the days of stay in hospital. 8. To establish the prognostic factors of mortality in each pathology. 9. To compare the IAP values of the severe acute pancreatitis with or without necrosis. The most important contributions of this study are the validation of the IAP determination with 50 mL of isotonic saline solution, the establishment the worst IAP as the best IAP to study the ACS, to associate the increment of the IAP with several organ dysfunction and mortality and to establish a different IAP value to predict several organ dysfunction and mortality in each group of patients. This study also suggests that we should use IAP to improve medical treatment and to help with the surgical decision

Síndrome compartimental abdominal en el paciente crítico con abdomen agudo y pancreatitis aguda grave

Descripció del recurs: el 12 de novembre de 2009La presión intraabdominal (PIA) es la presión dentro de la cavidad abdominal. El aumento de la misma o hipertensión intraabdominal (HIA) es ya conocida desde hace más de un siglo y se sabe que puede provocar alteraciones en la funcionalidad del organismo. En el año 1876 se relacionó el aumento de la PIA con la disfunción renal. Desde entonces y, sobretodo, durante la última década, han sido innumerables las referencias bibliográficas sobre la misma, su forma de medida y sus consecuencias. Así, en el año 2006 se definió, por una comisión de expertos, el síndrome compartimental abdominal (SCA) como aquella PIA 20 mmHg, mantenida y asociada a nueva o nuevas disfunciones orgánicas. A pesar de dicha comisión, siguen planteándose muchas preguntas sobre el método de determinación de la PIA y sobre qué medida de la misma considerar relevante en la evolución del paciente crítico, así como sus consecuencias clínicas. El presente trabajo estudia el valor de la PIA en dos tipos de pacientes críticos: en la pancreatitis aguda grave (grado E de Balthazar) y en el paciente postoperado de cirugía abdominal urgente. Los objetivos planteados son novedosos y útiles para la práctica clínica diaria. Dichos objetivos son mayoritariamente comunes a ambos grupos de pacientes: 1. Validación del método de determinación de la PIA con 50 mL de solución salina isotónica. 2. Validación del peor valor de PIA como la presión adecuada para realizar los estudios sobre SCA. 3. Comparar la PIA con otros factores pronósticos: APACHE II y PCR. 4. Demostrar que la PIA es marcador pronóstico del SCA y de mortalidad. 5. Establecer un valor de PIA pronóstico del SCA y de mortalidad. 6. Demostrar que la PIA es útil en la toma de decisiones terapéuticas y establecer un valor de PIA que determine un cambio en el tratamiento. 7. Demostrar que la PIA se relaciona con la estancia hospitalaria. 8. Establecer los factores pronósticos de mortalidad en esta patología. 9. Comparar la PIA de la pancreatitis aguda grave en función de si la etiología es biliar o enólica y en función de la presencia o no de necrosis. Dentro de las aportaciones derivadas de este trabajo destaca la validación de la determinación de la PIA intravesical con 50 mL de solución salina isotónica, establece como valor de PIA relevante en la práctica clínica diaria el peor valor de PIA a lo largo de la evolución de los pacientes, asocia el incremento de la PIA con la disfunción multiorgánica y la mortalidad y, establece un punto de corte diferente para cada grupo de pacientes a partir del cual se prevee el desarrollo de fallo orgánico y de muerte. También sugiere que la PIA es útil para optimizar el tratamiento médico y para ayudar en la toma de decisiones quirúrgicas.The intraabdominal pressure (IAP) is the pressure inside the abdomen. The increase in the abdominal pressure or intraabdominal hypertension (IAH) is well known since the nineteen century and is associated with multiple organ dysfunction. In the 1876 the IAH was related to renal dysfunction. Since then and specially during the last century, many studies were published about the abdominal compartment syndrome (ACS) and how to measure it. That's why an expert committee was created in 2004 and the first consensus about the ACS was published in 2006. The ACS was defined as sustained IAP > 20 mmHg associated with one o more new organ dysfunction. Despite this consensus there are still many controversial points such as which is the critical IAP that causes several organ dysfunction in the different critical patients. This work studies the predictive value of two types of critical patients: severe acute pancreatitis (grade E of Balthazar's classification) and patients after an abdominal surgery because of acute abdomen. The objectives studied are of great utility for the daily clinical practice. These objectives are common for both group of patients: 1. Validation of the IAP determination with 50 mL of isotonic saline solution. 2. Validation of the worse IAP as the best pressure to study the ACS. 3. Compare the IAP with other prognostic factors: APACHE II and reactive C protein. 4. To prove that IAP is a marker of the ACS and predictor of mortality. 5. To establish an IAP value to predict the ACS and mortality. 6. To prove that IAP is of great utility to make therapeutic decisions and to establish an IAP value that make change the treatment. 7. To prove the relation between the IAP and the days of stay in hospital. 8. To establish the prognostic factors of mortality in each pathology. 9. To compare the IAP values of the severe acute pancreatitis with or without necrosis. The most important contributions of this study are the validation of the IAP determination with 50 mL of isotonic saline solution, the establishment the worst IAP as the best IAP to study the ACS, to associate the increment of the IAP with several organ dysfunction and mortality and to establish a different IAP value to predict several organ dysfunction and mortality in each group of patients. This study also suggests that we should use IAP to improve medical treatment and to help with the surgical decision

Craniectomía descompresiva frente la hipertensión intracraneal

La craniectomia descompressiva es presenta com una estratègia terapèutica davant la hipertensió intracranial refractària al tractament mèdic. L'objectiu és avaluar els efectes de la CD en el resultat funcional dels pacients en els quals les mesures terapèutiques convencionals no aconsegueixen un control òptim de la pressió intracranial. Els resultats mostren que probablement la CD modifica l'evolució natural de la HTIC refractària disminuint la mortalitat, sense augmentar la morbiditat dels pacients, aconseguint un bon resultat funcional a l'any en més de la meitat dels pacients estudiats.La craniectomía descompresiva se presenta como estrategia terapéutica frente la hipertensión intracraneal refractaria al tratamiento médico. El objetivo es evaluar los efectos de la CD sobre el resultado funcional de los pacientes en los que las medidas terapéuticas convencionales no logran el control óptimo de la presión intracraneal. Los resultados muestran que probablemente la CD modifica la evolución natural de la HTIC refractaria disminuyendo la mortalidad, sin aumentar la morbilidad de los pacientes, alcanzando un buen resultado funcional al año en más de la mitad de los pacientes estudiados