RESUMEN
BACKGROUND: In critically ill patients, heparin-induced thrombocytopenia (HIT) is estimated to account for approximately 1 to 10% of all causes of thrombocytopenia. HIT exerts a strong procoagulant state. In case of suspected HIT, it is an important clinical decision to stop heparin and start treatment with alternative nonheparin anticoagulation, awaiting the results of laboratory testing for the final diagnosis of HIT (bridging therapy). Fondaparinux acts by factor Xa inhibition and expresses no cross-reactivity with HIT antibodies. Excretion of fondaparinux is mainly renal. We describe our early experience with fixed low-dose fondaparinux bridging therapy and monitoring of anticoagulant activity for safety reasons. METHODS: This retrospective cohort study was conducted in a closed format general intensive care unit in a teaching hospital. Consecutive critically ill patients suspected of HIT were treated with fondaparinux after discontinuation of unfractionated heparin or nadroparin. Anti-Xa levels were determined afterwards. RESULTS: Seven patients were treated with fondaparinux 2.5 mg/day for 1.8 to 6.5 days. Anti-Xa levels varied from 0.1 to 0.6 U/ml. A negative correlation was found between creatinine clearance and mean and maximum anti-Xa levels. No thromboembolic complications occurred. Bleeding complications were only minor during fondaparinux treatment. Transfusion requirements did not differ significantly between treatment episodes with fondaparinux or with heparin anticoagulants. CONCLUSION: In this small sample of critically ill patients suspected of HIT, bridging therapy with fixed low-dose fondaparinux resulted in prophylactic and therapeutic anti-Xa levels. Monitoring of anticoagulant activity is advised in patients with renal insufficiency.
Asunto(s)
Anticoagulantes/administración & dosificación , Cuidados Críticos/métodos , Heparina/efectos adversos , Polisacáridos/administración & dosificación , Trombocitopenia/inducido químicamente , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Anticoagulantes/farmacología , Quimioprevención , Enfermedad Crítica , Relación Dosis-Respuesta a Droga , Monitoreo de Drogas , Femenino , Fondaparinux , Hospitales de Enseñanza , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Polisacáridos/efectos adversos , Polisacáridos/farmacología , Estudios Retrospectivos , Trombocitopenia/sangreRESUMEN
OBJECTIVES: Critical illness increases the tendency to both coagulation and bleeding, complicating anticoagulation for continuous renal replacement therapy (CRRT). We analyzed strategies for anticoagulation in CRRT concerning implementation, efficacy and safety to provide evidence-based recommendations for clinical practice. METHODS: We carried out a systematic review of the literature published before June 2005. Studies were rated at five levels to create recommendation grades from A to E, A being the highest. Grades are labeled with minus if the study design was limited by size or comparability of groups. Data extracted were those on implementation, efficacy (circuit survival), safety (bleeding) and monitoring of anticoagulation. RESULTS: Due to the quality of the studies recommendation grades are low. If bleeding risk is not increased, unfractionated heparin (activated partial thromboplastin time, APTT, 1-1.4 times normal) or low molecular weight heparin (anti-Xa 0.25-0.35 IU/l) are recommended (grade E). If facilities are adequate, regional anticoagulation with citrate may be preferred (grade C). If bleeding risk is increased, anticoagulation with citrate is recommended (grade D(-)). CRRT without anticoagulation can be considered when coagulopathy is present (grade D(-)). If clotting tendency is increased predilution or the addition of prostaglandins to heparin may be helpful (grade C(-)). CONCLUSION: Anticoagulation for CRRT must be tailored to patient characteristics and local facilities. The implementation of regional anticoagulation with citrate is worthwhile to reduce bleeding risk. Future trials should be randomized and should have sufficient power and well defined endpoints to compensate for the complexity of critical illness-related pro- and anticoagulant forces. An international consensus to define clinical endpoints is advocated.
Asunto(s)
Anticoagulantes/administración & dosificación , Trastornos de la Coagulación Sanguínea/prevención & control , Terapia de Reemplazo Renal , Anticoagulantes/efectos adversos , Trastornos de la Coagulación Sanguínea/etiología , Pruebas de Coagulación Sanguínea , Medicina Basada en la Evidencia , HumanosRESUMEN
CASE PRESENTATION: Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate. TREATMENT: The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin B, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation. CONCLUSIONS: The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.
Asunto(s)
Artritis Reumatoide/complicaciones , Aspergilosis Broncopulmonar Alérgica/complicaciones , Herpes Simple/complicaciones , Tuberculosis/complicaciones , Anticuerpos Monoclonales/uso terapéutico , Antirreumáticos/uso terapéutico , Antituberculosos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Femenino , Humanos , Infliximab , Metotrexato/uso terapéutico , Persona de Mediana Edad , Tuberculosis/tratamiento farmacológicoRESUMEN
A 28-year-old female with a twin pregnancy at 29 6/7 weeks who was having premature uterine contractions developed acute respiratory failure due to sudden pulmonary oedema requiring mechanical ventilation. No evidence for venous thromboembolism, pulmonary infection or myocardial infarction was found. Subsequently a mild coagulopathy and foetal distress developed. Ultrasonography revealed oligohydramnios of one of the foetuses. A Caesarean section was performed and postoperatively mother and babies had an uneventful clinical course. By exclusion of other causes, we diagnosed severe maternal acute respiratory distress due to the amniotic fluid embolism syndrome in a twin pregnancy.
Asunto(s)
Embolia de Líquido Amniótico/complicaciones , Edema Pulmonar/etiología , Síndrome de Dificultad Respiratoria/etiología , Adulto , Cesárea , Diagnóstico Diferencial , Embolia de Líquido Amniótico/diagnóstico por imagen , Embolia de Líquido Amniótico/terapia , Femenino , Humanos , Trabajo de Parto Prematuro/etiología , Embarazo , Edema Pulmonar/terapia , Síndrome de Dificultad Respiratoria/terapia , Gemelos , UltrasonografíaRESUMEN
OBJECTIVE: To assess the optimal moment of central vascular catheter replacement balancing infectious and mechanical complications in continuous renal replacement therapies in critically ill patients with acute renal failure. METHODS: Prospective sequential trial with historical controls to compare liberal catheter replacement when clinically indicated with routine catheter replacement every 5 days in consecutive patients treated by continuous arteriovenous hemodiafiltration in a level I secondary referral intensive care unit of a university-affiliated teaching hospital. Intention-to-treat analysis. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients underwent catheter replacement when clinically indicated (group II), and 21 patients served as historical controls (group I). The groups were comparable for sex, age, Acute Physiology and Chronic Health Evaluation II scores, comorbidity, and creatinin and urea levels at the start of continuous arteriovenous hemodiafiltration. In group I, 71 catheters were used for 346 treatment days, and in group II, 68 catheters were used for 495 treatment days. The mean duration of catheterization was 4.9 +/- 2.0 days vs. 7.3 +/- 4.5 days, respectively (Student's t-test p <.001). There was no significant difference between the incidence of colonization of catheters (46.8% in group I vs. 39.1% in group II; chi-square p =.35) In group I, bacteremia and catheter sepsis occurred in two patients, whereas this did not occur in group II. The occurrence of mechanical complications was comparable in both groups (15.5% in group I vs. 19.1% in group II). There were significantly more mechanical complications with arterial vs. venous catheters (17 vs. 7; chi-square p =.027). CONCLUSION: When catheters were changed as clinically indicated, they remained significantly longer in situ vs. being replaced routinely every 5 days; infectious and mechanical complications were comparable. The incidence of catheter sepsis was low (2.2%), and no prosthesis infection occurred. Catheter replacement when clinically indicated seems to be as safe as routine replacement every 5 days.
Asunto(s)
Cateterismo Venoso Central/efectos adversos , Infección Hospitalaria/etiología , Hemodiafiltración , Síndrome de Dificultad Respiratoria/terapia , Sepsis/etiología , APACHE , Adulto , Anciano , Anciano de 80 o más Años , Contaminación de Equipos , Falla de Equipo , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Although the APACHE II score is the most widely used scoring system in intensive care units worldwide, its reliability and variability have not been extensively studied. Differences in case-mix may complicate comparison and interpretation of results. We hypothesised that a degree of variability might be inherent to use of the APACHE II scoring system, and decided to assess intra-observer variability in APACHE II scoring as a potential indicator of inherent score variability. APACHE II scores were assessed twice from the charts of 11 patients by 14 physicians, with a time interval of 4 (range 3.5-4.5) months between the two assessments. Intra-observer was found to be approximately 15%. These findings are in agreement with previous observations regarding inter-observer variability in APACHE II scoring, and strongly suggest that there is an inherent score variability of about 15%.
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APACHE , Análisis de Varianza , Factores de Confusión Epidemiológicos , Cuidados Críticos/normas , Grupos Diagnósticos Relacionados/clasificación , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Estudios de Seguimiento , Guías como Asunto , Humanos , Capacitación en Servicio , Cuerpo Médico de Hospitales/educación , Cuerpo Médico de Hospitales/normas , Variaciones Dependientes del Observador , Sensibilidad y Especificidad , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: To present our observation of the development of a rare nail deformity in the prolonged course of disease of a critically ill patient with a pulmonary abscess. DESIGN: Case report. SETTING: Tertiary referral, 16-bed, level I surgical ICU in an academic hospital. PATIENT: A 48-year-old Caucasian male was treated with penicillin for a pneumococcal meningitis and pneumonia. He developed a large pulmonary abscess of the right upper lobe and needed prolonged mechanical ventilation. Extensive surgical treatment was successful eventually. A remarkable feature concerned the occurrence of onycholysis of all finger nails and toe nails resulting in complete shedding of the nails (onychomadesis). This phenomenon can be regarded as an extreme manifestation of Beau's lines precipitated by a severe systemic insult. CONCLUSION: We observed the development of onychomadesis in a critically ill patient with a large pulmonary abscess. This association has not been described before.
Asunto(s)
Absceso Pulmonar/complicaciones , Uñas Malformadas/etiología , Alcoholismo/complicaciones , Enfermedad Crítica , Humanos , Huésped Inmunocomprometido , Unidades de Cuidados Intensivos , Absceso Pulmonar/etiología , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: Whole-body hyperthermia (WBH) in combination with chemotherapy is a relatively new promising treatment modality for patients with cancer. The objective of this report is to present the development of an acute systemic inflammatory response syndrome (SIRS) with multiple organ dysfunction syndrome (MODS) following WBH in combination with chemotherapy. Although WBH can also induce cytokine production, MODS has not been described before in association with WBH. DESIGN: Case report. The patient was treated with WBH (core temperature 41.8 degrees C using a radiant heat device (Aquatherm) ) in combination with polychemotherapy (ifosfamide, carboplatin and etoposide (ICE) ) in the context of a clinical trial for metastatic sarcomas. SETTING: Department of medical oncology and intensive care unit of a university hospital. PATIENT: A 58-year-old Caucasian woman treated for disseminated leiomyosarcoma of the uterus, who developed SIRS with brain dysfunction, hypotension, respiratory failure and renal dysfunction following WBH/ICE. INTERVENTIONS: She was successfully treated in the intensive care unit by mechanical ventilation, inotropics and antibiotics. MEASUREMENTS AND RESULTS: There was a remarkable recovery within 2 days: she regained full conciousness, could be extubated, inotropic support was stopped and creatinine levels returned to pre-treatment levels. All cultures remained sterile. After almost complete recovery, 5 days later a second episode of fever during neutropenia occurred and, despite antibiotic treatment, she died of Bacteroides distasonis sepsis. CONCLUSION: WBH should be added as a new cause to the already known list of physical-chemical insults which can result in MODS.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Hipertermia Inducida/efectos adversos , Leiomiosarcoma/complicaciones , Insuficiencia Multiorgánica/etiología , Neoplasias Uterinas/complicaciones , Infecciones por Bacteroides/diagnóstico , Infecciones por Bacteroides/etiología , Candidiasis/diagnóstico , Candidiasis/etiología , Terapia Combinada , Resultado Fatal , Femenino , Humanos , Leiomiosarcoma/terapia , Persona de Mediana Edad , Insuficiencia Multiorgánica/diagnóstico , Recurrencia Local de Neoplasia/complicaciones , Recurrencia Local de Neoplasia/terapia , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Neoplasias Uterinas/terapiaRESUMEN
In 2 patients with severe haemorrhage (a 63-year-old man with haemophilia A (the factor VIII level was 29%) and a 44-year-old woman), of an inhibitory antibody against factor VIII was diagnosed. The development of recombinant factor VIIa (eptacog alpha) has made available a new therapeutic option for patients with an inhibitory antibody against a coagulation factor. Both patients were treated successfully with the new factor after other forms of treatment had failed. The new concept of the coagulation cascade on which the treatment with eptacog alpha is based assumes that the lack of an amplifying loop in the coagulation which takes place via factor IX (in combination with factor VIII) can be compensated by extra stimulation of the principal route (tissue factor-factor VIIa --> factor X) by pharmacological amounts of factor VIIa.
Asunto(s)
Factor VIII/inmunología , Factor VIIa/administración & dosificación , Hemofilia A/inmunología , Hemorragia/tratamiento farmacológico , Adulto , Anticuerpos/análisis , Coagulación Sanguínea/efectos de los fármacos , Coagulación Sanguínea/fisiología , Femenino , Hemorragia/etiología , Hemostasis/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Proteínas RecombinantesRESUMEN
A 20-year-old man was hospitalised because he nearly suffocated when lying on his back. After bronchoscopy which revealed severe external compression of the airways, suddenly respiratory insufficiency developed. Because a malignant lymphoma was suspected chemotherapy was started, using monotherapy with prednisolone as the risk of acute tumour lysis syndrome (ATLS) is high with polychemotherapy of bulky tumours. Nevertheless ATLS developed, for which haemodialysis had to be applied. The tumour, a T-cell lymphoblastic non-Hodgkin lymphoma with high grade malignancy, was treated successfully with cyclophosphamide, doxorubicin, vincristine en prednisone. ATLS is characterized by hyperkalaemia, hyperuricaemia, hyperphosphataemia, hypocalcaemia, lactate acidosis and acute renal failure. It can occur in the course of aggressive cytoreductive therapy in rapidly growing lymphoproliferative malignancies with large tumour size, due to massive tumour cel lysis. Corticosteroid monotherapy is a very rare cause of ATLS.
Asunto(s)
Antineoplásicos Hormonales/efectos adversos , Linfoma de Células T/tratamiento farmacológico , Prednisolona/efectos adversos , Neoplasias Torácicas/tratamiento farmacológico , Síndrome de Lisis Tumoral/etiología , Enfermedad Aguda , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Humanos , Linfoma de Células T/complicaciones , Masculino , Diálisis Renal , Síndrome de la Vena Cava Superior/etiología , Neoplasias Torácicas/complicaciones , Síndrome de Lisis Tumoral/terapiaRESUMEN
A 45-year-old Caucasian woman presented with superficial thrombophlebitis of the right arm and right anterior thoracic wall after bilateral breast surgery followed by spontaneous left anterior thoracic vein thrombophlebitis 3 months later. Besides breast surgery and use of oral contraceptives, hereditary protein C deficiency and anticardiolipin antibodies were found as causes for this bilateral Mondor's disease.
Asunto(s)
Anticuerpos Anticardiolipina , Mama/irrigación sanguínea , Mamoplastia , Complicaciones Posoperatorias , Deficiencia de Proteína C , Tromboflebitis/etiología , Mama/cirugía , Femenino , Humanos , Persona de Mediana EdadRESUMEN
OBJECTIVE: Identification of risk factors for bleeding and prospective evaluation of two bleeding risk scores in the treatment of acute venous thromboembolism. DESIGN: Secondary analysis of a prospective, randomized, assessorblind, multicenter clinical trial. SETTING: One university and 2 regional teaching hospitals. PATIENTS: 188 patients treated with heparin or danaparoid for acute venous thromboembolism. MEASUREMENTS: The presenting clinical features, the doses of the drugs, and the anticoagulant responses were analyzed using univariate and multivariate logistic regression analysis in order to evaluate prognostic factors for bleeding. In addition, the recently developed Utrecht bleeding risk score and Landefeld bleeding risk index were evaluated prospectively. RESULTS: Major bleeding occurred in 4 patients (2.1%) and minor bleeding in 101 patients (53.7%). For all (major and minor combined) bleeding, body surface area < or = 2 m2 (odds ratio 2.3, 95% CI 1.2-4.4; p = 0.01), and malignancy (odds ratio 2.4, 95% CI 1.1-4.9; p = 0.02) were confirmed to be independent risk factors. An increased treatment-related risk of bleeding was observed in patients treated with high doses of heparin, independent of the concomitant activated partial thromboplastin time ratios. Both bleeding risk scores had low diagnostic value for bleeding in this sample of mainly minor bleeders. CONCLUSIONS: A small body surface area and malignancy were associated with a higher frequency of bleeding. The bleeding risk scores merely offer the clinician a general estimation of the risk of bleeding. In patients with a small body surface area or in patients with malignancy, it may be of interest to study whether limited dose reduction of the anticoagulant drug may cause less bleeding without affecting efficacy.
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Sulfatos de Condroitina/efectos adversos , Dermatán Sulfato/efectos adversos , Fibrinolíticos/efectos adversos , Hemorragia/epidemiología , Heparina/efectos adversos , Heparitina Sulfato/efectos adversos , Tromboembolia/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Acenocumarol/administración & dosificación , Acenocumarol/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Superficie Corporal , Sulfatos de Condroitina/administración & dosificación , Sulfatos de Condroitina/uso terapéutico , Comorbilidad , Dermatán Sulfato/administración & dosificación , Dermatán Sulfato/uso terapéutico , Combinación de Medicamentos , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/uso terapéutico , Hemorragia/inducido químicamente , Heparina/uso terapéutico , Heparitina Sulfato/administración & dosificación , Heparitina Sulfato/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/epidemiología , Oportunidad Relativa , Estudios Prospectivos , Factores de Riesgo , Método Simple CiegoRESUMEN
Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.
Asunto(s)
Enfermedades de la Aorta/cirugía , Fístula/cirugía , Fístula Intestinal/cirugía , Anciano , Prótesis Vascular , Resultado Fatal , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
In a prospective study the diagnostic value of compression ultrasonography (CUS) versus Duplex scanning (DS) in the non-invasive detection of acute femoropopliteal deep venous thrombosis (DVT) was determined. In 114 eligible patients clinically suspected of DVT of the lower extremity, compression ultrasonography and Duplex scanning were performed within 24 hours by different assessors unaware of the outcome of the other test. In 109 patients concordant results of combined compression ultrasonography and Duplex scanning were obtained and considered as a proof of the absence or presence of deep venous thrombosis and no subsequent invasive investigations were performed. In five patients compression ultrasonography and Duplex scanning were discordant and contrast venography was performed. Femoropopliteal thrombosis was present in 47 legs (41%). The sensitivity, specificity and accuracy of compression ultrasonography were 93.6, 97.0 and 95.6%, respectively, and of Duplex scanning 100, 98.5 and 99.1%, respectively. We conclude that compression ultrasonography and Duplex scanning are methods with comparably high accuracy. Because of its availability, accuracy, cost-effectiveness and simplicity we recommend compression ultrasonography as the primary diagnostic test in the detection of deep venous thrombosis.
Asunto(s)
Tromboflebitis/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Flebografía , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , UltrasonografíaRESUMEN
A patient with congenital situs inversus totalis and a single coronary artery was referred for revascularization because of progressive disabling angina. Exercise thallium scintigraphy had disclosed ischaemia in the anterolateral, posterolateral, and inferior wall of the left ventricle. Percutaneous transluminal coronary angioplasty was performed successfully for stenoses in the right coronary artery.