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El trasplante renal (TR) con riñones de donantes fallecidos en parada cardíaca (PC) está creciendo en nuestro país. La mayoría procede de donantes con los criterios de Maastricht tipo II, si bien en los últimos años el donante fallecido tras limitación de tratamientos de soporte vital (LTSV) es una realidad en algunos países europeos y norteamericanos y constituye el Maastricht tipo III. Se presenta una serie de 6 TR con riñones de donantes fallecidos tras PC como consecuencia de LTSV en tres hospitales del Sector Málaga. Tras consensuar protocolo de actuación en el que la valoración como donante fue siempre posterior a la decisión de LTSV, se planteó a las familias la opción de donación. La preservación de los riñones se realizó mediante sonda de doble balón tipo Porges que se colocó antes de la PC. En dos casos la LTSV se realizó en la Unidad de Cuidados Intensivos y en el tercero en quirófano. Los tiempos desde inicio LTSV hasta la PC oscilaron entre 15 y 40 minutos, con un tiempo de parada circulatoria antes del inicio de la (..) (AU)

Kidney transplantation (KT) with kidneys from non-beating-heart donors (NBHD) is a growing trend in Spain. The majority of these kidneys come from type II Maastricht patients, although in recent years, organ donations from patients deceased due to cardiac arrest following limitation of life-sustaining therapy has already been in practice in certain European and North American countries, and it involves type III Maastricht patients. We present a series of 6 KT using kidneys from NHBD as a consequence of limitation of life-sustaining therapy in three different hospitals in the sector of Malaga. After agreeing upon a protocol for evaluating the potential of a patient for organ donation, which was always after deciding to limit life-sustaining therapy, the patients' families were given the option of organ donation. Kidneys were preserved using a Porges double balloon catheter, which was placed prior to cardiac arrest. In two cases, the limitation of life-sustaining therapy took place in the intensive care unit, and in the third case, in the operating room. The interval between limitation of life-sustaining therapy and cardiac (..) (AU)

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Kidney transplantation (KT) with kidneys from non-beating-heart donors (NBHD) is a growing trend in Spain. The majority of these kidneys come from type II Maastricht patients, although in recent years, organ donations from patients awaiting cardiac arrest following limitation of life-sustaining therapy has already been in practice in certain European and North American countries, involving type III Maastricht patients. We present a series of 6 KT using kidneys from NHBD as a consequence of limitation of life-sustaining therapy in three different hospitals in the sector of Malaga. After agreeing upon a protocol for evaluating the potential of a patient for organ donation after the decision for limiting life-sustaining therapy, the patients' families were given the option of organ donation. Kidneys were preserved using a Porges double balloon catheter, which was placed prior to cardiac arrest. In two cases, the limitation of life-sustaining therapy took place in the intensive care unit, and in the third case, in the operating room. The interval between limitation of life-sustaining therapy and cardiac arrest ranged between 15 minutes and 40 minutes, with an interval of circulatory arrest prior to perfusion of 5-11 minutes. Perfusion-cooling of the kidneys was initially carried out using saline solution, followed by organ preservation solution (Celsior or Belzer) and extraction of the kidney using a rapid surgical technique. True or functional hot ischaemia times were 60 minutes, 59 minutes, and 50 minutes, respectively, for each of the three donors. Kidneys were evaluated for viability using time intervals for the procedure (including hypotension prior to cardiac arrest), macroscopic appearance, and histopathology of a sample taken from each kidney. The recipients of these 6 kidneys had given their consent to receive organs from expanded-criteria donors. Cold ischaemia lasted between 9 hours and 20 hours (mean: 14.6 hours). One recipient developed haemorrhagic complications during the immediate postoperative period and required a transplantectomy. The other five currently retain functioning grafts. All had delayed graft function, necessitating haemodialysis. The range of estimated glomerular filtration rates at the most recent follow-up evaluation was 23.0-106 ml/min/1.73 m(2). In conclusion, type III Maastricht donors provide valid kidneys for transplantation, although this series showed that supported functional hot ischaemia was very important, the consequence of accumulated ischaemic damage starting in the agonal phase, circulatory arrest, and organ preservation using cold solutions. As such, to improve the quality of results obtained using kidneys from these types of donors would involve a very careful selection of optimal donors and minimisation of total functional ischaemia times.

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OBJECTIVE: To estimate the usefulness of 2-h creatinine clearance (CrCl) in the ICU and define variables that may reduce agreement. DESIGN: Prospective study. SETTING: Polyvalent ICU of a university hospital. PATIENTS: 359 patients. INTERVENTIONS: We compared 24-h CrCl (CrCl-24h), as the standard measure, with 2-h CrCl (CrCl-2h) (at the start of the period) and the Cockroft-Gault equation (Ck-G). MEASUREMENTS AND RESULTS: The 2-h sample was lost in two patients (0.6%) and the 24-h sample was lost in 50 patients (13.9%). The mean Ck-G was 87.4+/-3.05, with CrCl-2h 109.2+/-4.46 and CrCl-24h 100.9+/-4.21 ml/min/1.73 m2 (r2 of 0.88 for CrCl-2h and 0.84 for Ck-G). The differences from ClCr-24h were 21.8+/-3.3 (p<0.001) for the Ck-G and 8.3+/-2.6 (p<0.05) for CrCl-2h (p<0.05). In the subgroup of patients with CrCl-24h<100 ml/min/1.73 m2, the CrCl-24h value was 52.9+/-2.71 vs. 51.6+/-2.14 for CrCl-2h (p=ns) and 57.6+/-2.56 (p<0.001) for the Ck-G. Patients with CrCl<100 ml/min only showed variability in hyperglycemia during the 24-h period. CONCLUSIONS: In intensive care patients, 24-h CrCl results in a large proportion of non-valid determinations, even under conditions of close monitoring. Two-hour CrCl is an adequate substitute, even in patients who are unstable or who have irregular diuresis where a 24-h collection is impossible. The Cockroft-Gault equation seems less useful in this setting.

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BACKGROUND: Dysautonomic crises represent a relatively unknown complication in patients with severe traumatic brain injury (TBI). Few studies have been undertaken of their pathophysiology and prognostic repercussions. We studied the prevalence of dysautonomic crises after TBI, their radiologic substrate, influence on the clinical course in the intensive care unit (ICU), and effect on neurologic recovery. METHODS: A case-control study involving 11 patients with dysautonomic crises admitted with TBI during a span of 1 year and 26 patients admitted with TBI but no crises during the first 3 months of the same year. The initial severity was assessed from Apache II, Glasgow Coma Scale (GCS) scores, and computed tomography (CT) during the first 24 hours. Complications were assessed by the duration of ICU stay, days on mechanical ventilation, need for tracheotomy, and number of infectious complications. Neurologic recovery was assessed with the GCS at discharge from the ICU and with the Glasgow Outcome Scale 12 months later. RESULTS: Both groups were similar at admission. The prevalence of dysautonomic crises was 9.3%. Patients with dysautonomic crises had more focal lesions on cranial CT than patients without crises, a significantly longer ICU stay, and a tendency to have a worse level of consciousness at discharge from the ICU but not 12 months later. CONCLUSIONS: Almost 10% of patients with severe TBI have dysautonomic crises during their ICU stay. Patients with dysautonomia were more likely to have focal intraparenchymal lesions, and crises were associated with greater morbidity and a longer ICU stay. Dysautonomic crises determined a worse short-term neurologic recovery.

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We examined whether hemodynamic improvement after high-flow hemofiltration predicts survival in patients treated with standard continuous renal replacement therapy (CRRT). This was a prospective, observational cohort study of 169 patients, measuring the mean arterial pressure (MAP) and norepinephrine (NE) dosage before and 24 hours after CRRT. Responders were defined as having a 20% reduction in NE dosage or a 20% rise in MAP with no increase in NE, compared with nonresponders. Patients were considered to be unstable if they were receiving NE or their MAP was lower than 60 mm Hg before CRRT. Of the 169 patients, 68% were men; mean age was 53.8 years (52.7 to 54.9), with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II at admission of 21.8 (21.2 to 22.3), of whom 114 were unstable at the start of CRRT. Overall mortality rate 15 days after the end of CRRT was 54.3% (57.7% in stable vs. 52.9% in unstable patients, p = NS). There were 99 responders and 70 nonresponders, the only differences being NE dosage (higher in responders, p < 0.01) and mortality rate (responders 30% vs. nonresponders 74.7%, p < 0.001). In unstable patients, mortality rate was 30% in responders versus 87% in nonresponders (p < 0.001) (72% sensitivity and 86% specificity for predicting death). Logistic regression analysis showed that the only variables associated with death were APACHE II at admission (OR, 1.06; 95% CI, 1.0 to 1.12), percent creatinine decrease (OR, 0.98; CI, 0.96 to 1.0), and lack of hemodynamic response to CRRT (OR, 7.04; CI, 3.3 to 15.02). Hemodynamic improvement after 24-hour CRRT is a strong predictor of survival.

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BACKGROUND AND OBJECTIVE: C-reactive protein (CRP) has been considered a marker for infection and an aid for diagnosing sepsis. We analyze the relation of CRP to infection and outcome in intensive care units (ICU) patients. PATIENTS AND METHOD: Prospective study on 77 ventilated patients. Expected short ICU stay or (suspected or confirmed) infection at admission were excluding criteria. 55 admissions after elective surgery were the controls. CRP measurement the first (CRP-1), third (CRP-3) and sixth (CRP-6) day of stay. APACHE II (Acute Physiology Score and Chronic Health Evaluation), SOFA (Sepsis-related Organ Failure Assessment), shock, respiratory or renal failure, leucocytes, platelets and albumin were registered. Follow-up until day 9 for infection and ICU discharge for outcome. RESULTS: CRP-1 in controls was 5.3 (3.9) mg/l and cases 67.8 (77.4) (p < 0.001). Shock on admission was related to CRP-1: patients in shock had higher CRP-1 levels (118.6 [82.8] vs 62.8 [75.6]; p = 0.06). 40.25% of cases developed infection, and CRP-1 levels were higher in this patients (88.8 [93.9] vs 53.8 [60.9]; p < 0.05). ROC area under curve was 0.6 with a sensibility of 23% and a specificity of 89% for a level of CRP-1 > 100. Mortality was 23.4% in cases and 1.8% in controls. Age, shock, APACHE II and SOFA were related to mortality, but CRP-1 did not. ROC area under curve for CRP-1 as mortality predictor in all patients was 0.62 (0.76 for APACHE II and 0.77 for SOFA) but only in cases was of 0.49 (0.69 for APACHE II and 0.67 for SOFA). CONCLUSIONS: CRP level on admission is an useful marker for early infection but not for outcome in critically ill patients admited to the ICU.

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Fundamento y objetivo: Analizar la utilidad de la proteína C reactiva (PCR) como marcador pronóstico y de infección en pacientes ingresados en unidades de cuidados intensivos (UCI). Pacientes y método: Se ha realizado un estudio prospectivo en 77 pacientes ventilados mecánicamente sin infección (sospechada o confirmada) en el momento del ingreso; el grupo control estuvo formado por 55 ingresos tras cirugía electiva. Determinamos el valor de PCR los días 1 (PCR-1), 4 (PCR-4) y 7 (PCR-7). Se registraron el APACHE-II (Acute Physiology Score and Chronic Health Evaluation) y SOFA (Sepsis-related Orgam Failure Assessment) al ingreso y la presencia de shock, fallo respiratorio o renal, así como la cifra de leucocitos, plaquetas y albúmina sérica durante el seguimiento (10 días para el análisis de infecciones y hasta el alta de la UCI para el del pronóstico). Resultados: El valor medio (desviación estándar) de la PCR-1 en los controles fue de 5,3 (3,9) mg/l, frente a 67,8 (77,4) mg/l en los casos (p < 0,001). Los casos con shock en el momento del ingreso presentaron valores más elevados de PCR-1 (118,6 [82,8] frente a 62,8 [75,6] mg/l, p = 0,06). El 40,25% de los casos desarrolló infección y presentó valores de PCR-1 más elevados (88,8 [93,9] comparado con 53,8 [60,9] mg/l, p < 0,05). La sensibilidad fue del 23% y la especificidad del 89% para un valor de PCR-1 superior a 100 (area bajo la curva de 0,6). Las mortalidad en los casos fue del 23,4%. La PCR-1 no se relacionó con el pronóstico en este grupo: el área bajo la curva para PCR-1 mayor de 100 como predictor de mortalidad en toda la población fue de 0,62, pero en los casos fue sólo de 0,49 (0,69 para APACHE-II y 0,67 para SOFA). Conclusiones: El valor sérico de la PCR en el momento del ingreso es un marcador temprano de infección pero no es útil como marcador pronóstico en pacientes críticos sometidos a ventilación mecánica al ingresar en la UCI

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Renal dysfunction (RD) is a frequent complication after orthotopic liver transplantation (OLT), and it has an unfavorable effect on the prognosis of OLT patients. The purpose of our study was to identify possible risk factors for RD and its impact on survival. The possible relations of pre-, peri-, and postoperative variables to early-onset renal dysfunction (ED) (within the 1st 3 months), late-onset renal dysfunction (LD) (between 3 and 6 months), and chronic renal dysfunction (CRD) (beyond 6 months) was analyzed. We studied 245 liver transplants in 241 patients. RD was found in 64.1% of these patients, and 69% of the patients with RD recovered. LD was found in 16.7% of the transplant patients. In the multivariate analysis, baseline serum creatinine, perioperative volume of transfused bank-red blood cells, Acute Physiology and Chronic Health Evaluation (APACHE) II score at intensive care unit (ICU) admission, and infection were associated with the development of RD. Overall mortality was 27.8% and for the RD group, it was 33.5%. LD, but not ED, was related to lower survival (together with graft dysfunction and APACHE II score at ICU admission). In conclusion, ED is frequent alter OLT and is related to preexisting RD, the volume of transfused bank--red blood cells during surgery, higher APACHE II score at ICU admission, and infection. In general, the prognosis for ED is good, in contrast with that of LD, which is associated with diminished survival.

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BACKGROUND AND OBJECTIVE: Liver transplant is an effective procedure for fulminant hepatitis or chronic liver disease and offers an adequate quality of life. However, even though it is a consolidated treatment, patients can develop serious complications in the immediate postoperative course. PATIENTS AND METHOD: Prospective observational study of 131 patients admitted in our intensive care unit after liver transplant surgery. We studied variables related with the development of complications and their relation to outcome. RESULTS: Intensive care unit mortality was 11.5%. Median stay was 4 days. 90% of patients presented 2 or more complications. Hyperglycemia, thrombocytopenia and hypothermia were the most frequent complications but they were not related with mortality. Less frequent but related to outcome complications were acute renal failure (23.6% mortality vs. 1.3%; p < 0.01), ADRS (63.6% vs 6.7%; p < 0,01), low cardiac output (71.4% vs 4.3%; p < 0.01), > or = 2 vasoactive drugs (61.9% vs 1.8%; p < 0.01), encephalopathy (37.5% vs 9.8%; p < 0.05), pneumonia (80% vs 8%; p < 0.01) and hemorrhage (29.4% vs 8.8%; p < 0.05). Graph ischemia, coagulopathy, reperfusion syndrome and use of blood derivatives during surgery were factors related with the development of complications and mortality. Multivariate analysis showed a relationship with mortality and low cardiac output, number of vasoactive drugs and total time of graft ischemia. CONCLUSIONS: Complications during the postoperative course of liver transplant are frequent but most of them have no effect on prognosis. The negative effect of severe complications should be limited by optimizing the hemodynamic support in these patients and minimizing ischemia of transplanted organs.

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