Acta Colombiana de Cuidado Intensivo最新文献

Maternal mortality attributed to severe acute respiratory distress syndrome (ARDS) during pregnancy accounts for approximately 30-50% of all cases in pregnant individuals affected by this condition, while the mortality rate during the puerperal period ranges from 20-25%. Furthermore, there are notable incidences of spontaneous neonatal mortality and preterm births accompanied by disruptions in cardiac rhythm and frequency resulting from maternal hypoxemia.

We present a case study of a 21-year-old female, 37.6 weeks pregnant, who was admitted to a tertiary-level gynecology-obstetrics emergency department with severe ARDS caused by community-acquired atypical pneumonia. The patient necessitated early initiation of extracorporeal membrane oxygenation (ECMO) and was successfully transferred to a designated Center of Excellence for further management. After receiving 37 days of comprehensive supportive care and undergoing successful decannulation, she was discharged home following a total of 68 days of hospitalization.

Severe ARDS represents a clinical entity associated with considerable mortality, particularly within the vulnerable population of pregnant women, significantly impacting the maternal-fetal dyad. The therapeutic escalation, including the incorporation of ECMO, should be readily available in all healthcare facilities. Collaborative efforts among institutions serve as a catalyst for advancements in medical practice, particularly in resource-constrained settings, paralleling the strategies employed in more developed nations.

We present the case of an 82-year-old woman with a prolonged hospital stay due to multiple complications secondary to major bile duct surgery for gallbladder carcinoma plus radical cholecystectomy plus trisegmental hepatectomy, she presented chronic diarrhea (3 months of evolution), accompanied by an episode of altered state of consciousness and convulsive episodes, with changes in ammonium levels (333 mmol/L) without changes in liver function.

Carnitine deficiency secondary to chronic diarrhea was considered the cause of hyperammonemia, and treatment was started, which consisted of extended hemodialysis-type renal replacement therapy, given the limitation for starting treatment with ammonium binders due to persistent diarrhea, just as it was started. loperamide, evidencing improvement in the state of consciousness and decrease in ammonium levels 133 mmol/L.

Multiple clinical situations can cause decompensation with hyperammonemia in a patient, being fatal, causing permanent or irreversible neurological damage. Hyperammonemia may be one of the neglected causes as encephalopathy in patients admitted to the intensive care unit, caused by a constellation of conditions, including medications, infections, liver compromise, parenteral nutrition, and many other causes. being overlooked, due to its scarce investigation.

The knowledge that allows an adequate and timely diagnosis, with the aim of reducing clinical decompensation and correct management in the acute phase, is essential to minimize fatal consequences.

Pulmonary thromboembolism is a frequent cause of cardiorespiratory arrest, this being an entity with specific treatment, which should be established even in cases with high clinical suspicion without confirmed diagnosis. Thrombolysis has shown good results in different outcomes. A 72-year-old diabetic, hypertensive, hyperthyroid patient is presented, hospitalized for an infected lower limb ulcer, who presented respiratory distress with subsequent ventilatory failure, shock and cardiorespiratory arrest, who was diagnosed with pulmonary thromboembolism due to ultrasound signs and was intra-arrest thrombolysis was performed, thereby achieving return to spontaneous circulation and gradual resolution of the shock. A review of the literature on intra-arrest thrombolysis is carried out, concluding that in pulmonary thromboembolism managing clinical risk is of vital importance, since those at high risk have higher mortality rates and the establishment of reperfusion measures are essential. In cardiorespiratory arrest with high suspicion of pulmonary thromboembolism, ultrasound is valuable to support the diagnosis and intrapartum thrombolysis has a higher rate of return to spontaneous circulation and even survival.

The neurocritical patient suffers from severe dysfunction of the central nervous system, generated by the alteration in his brain structure and function due to changes in his neuronal connections, neurotransmitters and autoregulation secondary to edema, ischemia or cerebral hemorrhage.

Neurobioethics is a variant of personalistic ethics that sees the person as unique and exceptional, applying the principle of defense of physical life, which promotes the integral and dual brain-mind good. The attention of the neurocritical patient in Intensive Care depends on the bioethical conduct «moral improvement» of the person who assumes and performs it. It is the interaction of the doctor who is conscious and the patient who is unconscious without autonomy. That is, it will depend on the doctor-patient relationship, the medical act, professional autonomy, not so much on the autonomy of the patient.

In order to carry out a critical reflection and a reflexive analysis for an argumentation based on the ethics and science of neurobioethics applied to the neurocritical patient in Intensive Care, a non-systematic review of neurobioethics, neuroscience and neuroethics applied to the patient was carried out. The objective is to raise ethical considerations of neurobioethics in the care of the neurocritical patient in Intensive Care.

Objectives

Primary outcome: To evaluate the capacity of different indices derived from the complete blood count (neutrophil-lymphocyte index, NLI and platelet-lymphocyte index, PLI), and biochemical markers of inflammation as predictors of mortality in adult critically ill patients with COVID-19. Secondary outcome: To evaluate those indices as predictors of the need for invasive mechanical ventilation (iMV).

Design

Observational, retrospective, single center cohort study.

Setting

Adult ICU.

Patients

Critically ill patients with COVID-19.

Intervention

None.

Variables

Acute Physiology and Chronic Health Evaluation II (APACHE II) score, comorbidities, need for iMV, days on iMV, prone position, status at ICU discharge (alive or deceased), leukocytes and their subpopulations: neutrophils, monocytes and lymphocytes, platelets, and the following inflammatory markers: ferritin, d-dimers, CRP, INL and IPL.

Results

N = 271. N = 155 (57.2%) were men, age 57.3 ± 14.2 years. Overall mortality was 51.3%, while mortality in those who required IMV was 76% (P < .001). The NLR in patients who survived the ICU was 11.9 ± 7.9, vs. 15.3 ± 14.7 in those who died (P = .02). The cut-off value of the NLR to predict the status at ICU discharge was 13.69 (AUC = 0.558; 95% CI: 0.489-0.626; P = .02), while the DD capacity to predict iMV was 1,009 (AUC = 0.588; 95% CI: 0.516-0.661; P = .01). In the multivariate analysis, none of the indices derived from the blood count or the inflammatory biomarkers were independently associated with ICU mortality.

Conclusion

Inflammatory indices such as INL and IPL showed poor predictive value for ICU mortality and iMV in critically ill adult patients with COVID-19.

The use of acrostics that represent the different steps of a process can improve learning, retention and speed of execution between the successive steps that make up the process.

This paper proposes the tool «GASTELE UN DIA», to be used as a checklist by the multidisciplinary clinical team involved in the management of a critically ill patient, facilitating an orderly mental scheme for safe, timely, effective, efficient and patient-centered management, reducing the attributable risk to care.

This tool takes into account Glycemic control, adequate Analgesia, goal Sedation, identification and management of delirium, Thromboprophylaxis, bedside Elevation, release of mechanical ventilation, bowel Evacuation, prevention and management of pressure Ulcers, gastric protection, appropriate Nutrition scheme, Diuresis monitoring, early withdrawal of Invasions and early adjustment of Antibiotic therapy. A review of the evidence is conducted for each management proposal.

Extracorporeal membrane oxygenation (ECMO) provides life support in cases of severe acute respiratory failure refractory to conventional management. Despite the improvement in survival in selected patients with severe ARDS, events of severe hypoxemia are not uncommon during support, for which it is necessary to identify the causes and promptly intervene in the patient and in the ECMO circuit. Recirculation, oxygen consumption imbalance, oxygenator failure, and decreased residual lung function are the main causes of severe hypoxemia even during ECMO.

A case of an obese patient with severe ARDS and refractory to SARS CoV-2 in need of ECMO support is described, who during his evolution presented episodes of severe hypoxemia even on ECMO, for which multiple interventions were necessary both in the circuit and in the patient to solve this complication.

This article presents a clinical case, a review of the literature, and a diagnostic and therapeutic algorithm for timely resolution of severe hypoxemia on ECMO.

Introduction

Ideal weight is considered as the weight determined for a given height; its calculation from equations allows in intensive care units to establish drug doses, prescribe nutritional intake and program the tidal volume in the mechanical ventilator.

Objective

To describe the knowledge, attitudes and practices of physiotherapists in 15 intensive care units in southwestern Colombia on the calculation of ideal weight between May-July 2021.

Methods

Cross-sectional observational study. A questionnaire was designed, validated and applied (google forms) based on 3 domains (knowledge, attitudes and practices), with a self-completion time of 12 minutes. The questionnaire was applied to 32 physiotherapists in 15 adult intensive care units, representing 60% of the total number of units in the city where the study was carried out.

Results

During the 7 months of data collection, a total of 32 physical therapists responded to the survey, with an overall response rate of 55%, 62% were women, the average age was 33, 62% had experience of more than 36 months and 25% had postgraduate training in the cardiopulmonary area. The content validity index of the questionnaire was 0.93, the knowledge domain was 0.90, attitudes 0.88 and practices 0.87.

Conclusión

100% of the physiotherapists have a high knowledge of the calculation of ideal weight in critical patients, practices differ among them and it is considered necessary to protocolize and standardize the measurement.

Organ donation in brain or neurological death is an accepted scientific and ethical procedure, however, the demand for transplants exceeds the supply of organs, having to resort to other forms of donation. To the so-called non-heart-beating donors described in the literature as uncontrolled asystolic donors and controlled asystolic donors, detected inside and outside the intensive care units. This new way of obtaining organs is becoming an increasingly accepted method in the world, due to the favorable results obtained.

The intensive care physician in end-of-life care requires knowledge of this new way of detecting donors in patients in imminent death with terminal catastrophic illness category Maastricht III. Where the vision of informed, subrogated consent, advance directives, autonomy, respect for dignity, rights, controlled withdrawal of life support, terminal extubation and circulatory arrest, must be taken into account before the decision of the patient or family member in their will to donate. To understand donors in controlled asystole, end-of-life care, and ethical issues in intensive care, a systematic review was performed using the ask Medline search tool in Medline/PubMed and three PICO questions related to the search were answered. Concepts of the terms used in end of life and DAC and ethical aspects and DAC were established according to the references.

The objective of this review was to know what is related to organ donation in controlled asystole, end-of-life care and its ethical aspects in intensive care.

Thromboembolic events related to SARS-CoV-2 in critically ill patients occur with great frequency according to the current literature. Taking into account the mortality rate related to thrombotic events, it is important to elucidate the role of therapeutic anticoagulation in this entity.

Objective

To characterize therapeutic anticoagulation in patients in an intensive care unit (ICU) with a confirmed diagnosis of SARS-CoV-2.

Materials and methods

Descriptive study of a retrospective case series made up of patients older than 18 years in the ICU of a hospital in Bogotá, Colombia, with a diagnosis of SARS-CoV-2 confirmed by RT-PCR test. Patients with therapeutic anticoagulation were included and those with coagulopathy and antithrombotic treatment prior to COVID-19 infection were excluded.

Results

A total of 174 patients met the criteria for inclusion in this study. Arterial hypertension was the pathology with the highest presentation with 47.1%. Unfractionated heparin was administered to 115 and low molecular weight heparin to 59. Adverse reactions derived from treatment represented 6.32% of the population. Regarding thromboembolic events, they were 37.36%, where deep vein thrombosis (DVT) predominated with 14.9%.

Conclusion

Hemorrhagic events occurred less frequently compared to thrombotic events, however, more clinical and analytical studies are needed to corroborate this approach.