Insulinoterapia Intensiva y Reanimación con Coloides (HES) en Sepsis Severa

Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis
Frank M. Brunkhorst, M.D., et al. for the German Competence Network Sepsis (SepNet)
N Engl J Med 2008;358(2):125-39.


Background
The role of intensive insulin therapy in patients with severe sepsis is uncertain. Fluid resuscitation improves survival among patients with septic shock, but evidence is lacking to support the choice of either crystalloids or colloids.

Methods
In a multicenter, two-by-two factorial trial, we randomly assigned patients with severe sepsis to receive either intensive insulin therapy to maintain euglycemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The rate of death at 28 days and the mean score for organ failure were coprimary end points.

Results
The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (112 mg per deciliter [6.2 mmol per liter]) than in the conventional-therapy group (151 mg per deciliter [8.4 mmol per liter], P<0.001). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycemia (glucose level, 40 mg per deciliter [2.2 mmol per liter]) was higher in the intensive-therapy group than in the conventional-therapy group (17.0% vs. 4.1%, P<0.001), as was the rate of serious adverse events (10.9% vs. 5.2%, P=0.01). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer's lactate.

Conclusions
The use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycemia. As used in this study, HES was harmful, and its toxicity increased with accumulating doses.

Hidrocortisona en el Shock Séptico

Hydrocortisone Therapy for Patients with Septic Shock
Charles Sprung, Djillali Annane, Didier Keh, et al. for the CORTICUS Study Group
N Engl J Med 2008;358(2):111-24.

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Background
Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin.

Methods
In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test.

Results
Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P=0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P=1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock.

Conclusions
Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed

Metaánalisis Resultados Colecistectomía Laparoscópica Precoz vs Diferida en Colecistitis Aguda

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials
Tamim Siddiqui, Alisdair MacDonald, Peter Chong and John Jenkins.
American Journal of Surgery 2008;195(1):40-47

Background
The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. More recent evaluation indicates early laparoscopic surgery may be a safe option in acute cholecystitis, although conversion rates may be higher. No conclusive evidence establishing best practice in terms of clinical benefit exists.

Methods
All randomized clinical studies published between 1987 and 2006 comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis were analyzed, irrespective of language, blinding, or publication status. Exclusions were quasi-randomized trials, inadequate follow-up description, or allocation concealment. Endpoints included conversion rates, postoperative complications, total hospital stay, and operation time. Random and fixed-effect models were used to aggregate the study endpoints and assess heterogeneity.

Results
Four studies containing 375 patients were included. No significant study heterogeneity or publication bias was found. There was no significant difference in conversion rates (odds ratio = .915 [95% confidence interval (CI), .567–1.477], P = .718) and postoperative complications (odds ratio = 1.073 [95% CI, .599–1.477], P = .813) between both groups. Operation time was significantly reduced (weighted mean difference [WMD] = .412 [95% CI, .149–.675], P = .002) with delayed cholecystectomy. The total hospital stay was significantly reduced (WMD = .905 [95% CI, .630–1.179], P = .0005) with early cholecystectomy. The postoperative stay was significantly reduced in the delayed group (WMD = .393 [95% CI, .128–.659], P = .004).

Conclusions
These meta-analysis data suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay at the cost of a significantly longer operation time with no significant differences in conversion rates or complications.

Dexmedetomidina es Mejor que Lorazepam Para Sedación de Pacientes Críticos en UTI: Resultados de MENDS

Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients: The MENDS Randomized Controlled Trial
Pratik Pandharipande; Brenda Pun; Daniel Herr; Mervyn Maze; Timothy Girard; Russell R. Miller; Ayumi Shintani; Jennifer Thompson; James Jackson; Stephen Deppen; Renee Stiles; Robert Dittus; Gordon Bernard; Wesley Ely.
JAMA. 2007;298(22):2644-2653.

Context
Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but this and other benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and coma, associated with prolonged hospital stays, costs, and increased mortality. Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction.

Objective
To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam.

Design, Setting, Patients, and Intervention
Double-blind, randomized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were titrated to achieve the desired level of sedation, measured using the Richmond Agitation-Sedation Scale (RASS). Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU).

Main Outcome Measures
Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal.

Results
Sedation with dexmedetomidine resulted in more days alive without delirium or coma (median days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P < .001) than sedation with lorazepam. Patients sedated with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients sedated with lorazepam (median percentage of days, 80% vs 67%; P = .04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the lorazepam group (P = .18) and cost of care was similar between groups. More patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to complete post-ICU neuropsychological testing, with similar scores in the tests evaluating global cognitive, motor speed, and attention functions. The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group (P = .48).

Conclusion
In mechanically ventilated ICU patients managed with individualized targeted sedation, use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion.

Conceptos Básicos de los Aneurismas de Aorta Abdominal (AAA)

Revisión publicada en Contemporary Surgery que resume lo mínimo que debe conocer un estudiante de medicina respecto a esta patología.

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Algunos Aspectos Referentes al Megacolon

Artículo de Contemporary Surgery. A raíz de un caso clínico aporta datos básicos referentes al cuadro clínico, estudio y manejo del megacolon.

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