Medicina intensiva
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Review
[Stress hyperglycemia and its control with insulin in critically ill patients: current evidence].
To analyze the current evidence on glycemic control with insulin therapy in the critically ill. ⋯ Stress hyperglycemia in critically ill patients has been associated with increased morbidity and mortality. Furthermore, current evidence suggests that glucose variability has a predictive value for hospital mortality. Initially, the Leuven studies showed that intensive insulin therapy was capable of reducing the mortality among surgical and medical ICU patients. Nevertheless, this strategy significantly increases the incidence of severe hypoglycemia. Three important trials on glucose control have been published recently: the VISEP, the Glucontrol study and the NICE-SUGAR. They have shown that strict control of glycemia is associated with a higher incidence of mortality and severe hypoglycemia. Furthermore, according to a recent meta-analysis, intensive insulin therapy may be beneficial for patients admitted to a surgical ICU. Further studies should be able to address some queries about these results on glycemic control in the critically ill.
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Nearly forty years ago, Swan and Ganz introduced pulmonary artery catheterization to monitor the hemodynamic status of critical patients. The need for pulmonary artery catheterization in clinical practice has been questioned because it may be related to increased mortality and because alternative techniques that will probably cause less morbidity and mortality have been developed. ⋯ This review aims to discuss the advantages and drawbacks of the Swan-Ganz catheter as the gold standard for monitoring hemodynamics in critical patients. We believe that combining the available techniques should help us evaluate the hemodynamics in critical patients and determine the cause of hemodynamic instability so we can select the most appropriate initial treatment and evaluate the subsequent response.
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The term Transfusion-Related Acute Lung Injury (TRALI) was coined in 1985. It is a relatively rare, life-threatening clinical syndrome characterized by acute respiratory failure and non-cardiogenic pulmonary edema during or following a blood transfusion. Although its true incidence is unknown, a rate 1 out of every 5000 transfusions has been quoted. ⋯ The first is a single antibody-mediated event involving the transfusion of anti-HLA or antigranulocyte antibodies into patients whose leukocytes express the cognate antigens. The second is a two-event model: the first event is related to the clinical condition of the patient (sepsis, trauma, etc.) resulting in pulmonary endothelial activation and neutrophil sequestration, and the second event is the transfusion of a biologic response modifier that activates these adherent polymorphonuclear leukocytes resulting in endothelial damage and capillary leak. The patient management is support as needed based on the severity of the clinical picture and strategies to prevent TRALI are focused on: donor-exclusion policies, product management strategies and avoidance of unnecessary transfusions.
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The pandemic strain of H1N1 supposes a challenge to the health care system in general and for Intensive Care Units (ICU) in particular. Therefore, it will undoubtedly have repercussions on the organ and tissue donation process. ⋯ Another problem related with the impact of the pandemic on the organ donation process is the possibility that a donor with influenza virus could transmit the disease to recipients. This work aims to clarify this issue, reviewing existing data on the potential transmission of influenza viruses with transplanted organs or tissue, the recommendations published in other countries and those developed in Spain by an ad hoc work group that is made up by representatives from the National Transplant Organization, the Ministry of Health and Social Policy, Regional Offices of Transplant Coordination, and various scientific societies, including SEMICYUC.
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Mechanical ventilation may cause and aggravate lung damage and contribute to the appearance of multiorgan failure. One of the mechanisms that has been described is alveolar hyperoxia. ⋯ Moreover, both the FiO(2) used as well as the PaO(2) achieved in the first 24h of admission are associated with mortality. Clinical trials are needed that assess the threshold of the safe oxygen level for FiO(2) and oxygen saturation.