En la ultima decada se ha observado un incremento de la literatura disponible sobre hipertension ... more En la ultima decada se ha observado un incremento de la literatura disponible sobre hipertension intrabdominal (HIA) y sindrome compartimental del abdomen. Dado las importantes implicancias fisiopatologicas del aumento de la presion intrabdominal (PIA) en la funcion de organos dentro y fuera del abdomen, este topico es y sera trascendente en los proximos anos para una poblacion de pacientes criticamente enfermos tanto neonatales, pediatricos como adultos. El objetivo de la presente revision es efectuar una puesta al dia sobre definiciones, epidemiologia, metodologia de medicion, implicancias fisiopatologicas, hallazgos radiologicos y opciones terapeuticas. Mensajes claves a conocer por el lector son: (1) el indice de masa corporal y la resucitacion con volumen predicen el desarrollo de HIA; (2) la HIA aumenta las presiones intratoracicas, intracraneana y de llenado cardiaco, y disminuye la compliance ventricular izquierda, de la pared toracica y total del sistema respiratorio; (3) la HIA causa atelectasia y aumenta el contenido de agua extravascular pulmonar; (4) la mejor presion positiva de fin de espiracion (PEEP) debe ser indicada para contrarrestar la HIA; (5) estrategias de ventilacion protectora deben de estar orientadas por DPpl (presion plateau-PIA); (6) presiones transdiafragmaticas e indicadores volumetricos reflejan mejor la precarga; (7) la HIA es un predictor independiente de falla renal aguda; (8) la HIA gatilla translocacion bacteriana y desarrollo de sindrome de falla organica multiple; (9) se recomienda la monitorizacion de la presion de perfusion abdominal en casos seleccionados
The objectives of the study were to assess organ dysfunction in burn patients by using the Sequen... more The objectives of the study were to assess organ dysfunction in burn patients by using the Sequential Organ Failure Assessment (SOFA) score, to determine the relationship between early (day 1) and late (day 4) organ dysfunction, as well as the change in organ dysfunction from admission to day 4, and mortality. The design was a prospective observational cohort study. Patients were admitted to our intensive care burn unit with severe thermal burns (> or =20% total body surface area [BSA] burned) or inhalation injury with a delay from injury to admission less than 12 h and a length of stay less than 3 days (n = 439; age, 46.0 +/- 20.3 yrs; total BSA burned, 31.6% +/- 20.2% [mean +/- SD]; inhalation injury, 44.4%; crude mortality, 18.5%). Sequential Organ Failure Assessment scores were measured on admission (SOFA 0) and on subsequent days (SOFA 1, SOFA 2, SOFA 3, and SOFA 4). The difference between SOFA 0 and SOFA 4 (DeltaSOFA 0-4) was calculated. Multivariate logistic regression analyses, including other variables associated with mortality in the models, were performed to calculate adjusted odds ratios (ORs) of organ dysfunction measurements for mortality. After adjusting for age, BSA burned, diagnosis of inhalation injury, and sex, SOFA 1 (OR, 1.89; 95% confidence interval [CI], 1.55-2.32), SOFA 4 (OR, 1.33; 95% CI, 1.19-1.47), and DeltaSOFA 0-4 (OR, 1.40; 95% CI, 1.28-1.55) were independently associated with mortality. The SOFA score is useful to assess organ dysfunction in burn patients. Burn-induced organ dysfunction (early and late), as well as the change in organ dysfunction, is independently associated with mortality.
To develop a model for predicting mortality among burn victims. All casualties admitted to our in... more To develop a model for predicting mortality among burn victims. All casualties admitted to our intensive care burn unit (ICBU) with a diagnosis of thermal or inhalation injury were studied. Age, total and full-thickness body surface area (BSA) burned, presence of inhalation injury, gender, mechanism of injury, delay to ICBU admission and mechanical ventilation during the first 72 h were recorded. The 851 participants were randomly divided into derivation (671) and validation (180) sets. From univariate and multivariate logistic regression analyses a mortality predictive equation was derived. Mortality was 17.6%. In univariate analysis, all variables were significantly associated with mortality except mechanism of injury and delay to ICBU admission. In multivariate analysis, age, total and full-thickness BSA burned, female gender and early mechanical ventilation were independently associated with mortality. We propose a mortality predictive equation for burned victims. In this model, MV and not inhalation injury is a mortality risk factor.
Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intest... more Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intestinal permeability, derangement in mucosal barrier functions and translocation of proinflammatory mediators. These changes can contribute to the pathogenesis of multiple organ failure. Vasoactive drugs such as dobutamine and dopexamine can improve splanchnic perfusion and gastric intramucosal pH during sepsis. However, contradictory results have been obtained with dopamine and norepinephrine. On the other hand, epinephrine further impairs splanchnic perfusion. In view of the contradictory effects of different vasoactive drugs, gastric tonometry must be measured during their use, to find the optimal drug combination that optimizes splanchnic blood flow.
Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which... more Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile. Methods Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4...
Paciente varón de 20 años, con diagnóstico de asma conocida, llegó al departamento de emergencias... more Paciente varón de 20 años, con diagnóstico de asma conocida, llegó al departamento de emergencias de un hospital de su localidad con historia de disnea 1 d antes de la admisión. Posteriormente, se torna taquicárdico, taquipneico y cianótico, por lo que fue intubado de emergencia. En la UCI del hospital general de tercer nivel, presentó bron- coespasmo grave, presiones de vía aérea elevadas durante la ventilación mecánica e hipoperfusión grave. Recibió cristaloides y norepinefrina como resucitación. Al tercer día, presentó enfsema subcutáneo, neumotórax e hipercapnia con acidosis mixta. Se decidió utilizar ventilación mecánica ultraprotectora asociada con Novalung . Con esta estrategia, logramos reducir las presiones de la vía aérea, la PEEPi, la potencia mecánica (PM) resistiva y mejorar la hipercapnia y la acidosis. El paciente permaneció 10 d en Novalung y mostró buena evolución posterior. Finalmente, es extubado, dado de alta de la UCI y salió del hospital en buenas condiciones.
En la ultima decada se ha observado un incremento de la literatura disponible sobre hipertension ... more En la ultima decada se ha observado un incremento de la literatura disponible sobre hipertension intrabdominal (HIA) y sindrome compartimental del abdomen. Dado las importantes implicancias fisiopatologicas del aumento de la presion intrabdominal (PIA) en la funcion de organos dentro y fuera del abdomen, este topico es y sera trascendente en los proximos anos para una poblacion de pacientes criticamente enfermos tanto neonatales, pediatricos como adultos. El objetivo de la presente revision es efectuar una puesta al dia sobre definiciones, epidemiologia, metodologia de medicion, implicancias fisiopatologicas, hallazgos radiologicos y opciones terapeuticas. Mensajes claves a conocer por el lector son: (1) el indice de masa corporal y la resucitacion con volumen predicen el desarrollo de HIA; (2) la HIA aumenta las presiones intratoracicas, intracraneana y de llenado cardiaco, y disminuye la compliance ventricular izquierda, de la pared toracica y total del sistema respiratorio; (3) la HIA causa atelectasia y aumenta el contenido de agua extravascular pulmonar; (4) la mejor presion positiva de fin de espiracion (PEEP) debe ser indicada para contrarrestar la HIA; (5) estrategias de ventilacion protectora deben de estar orientadas por DPpl (presion plateau-PIA); (6) presiones transdiafragmaticas e indicadores volumetricos reflejan mejor la precarga; (7) la HIA es un predictor independiente de falla renal aguda; (8) la HIA gatilla translocacion bacteriana y desarrollo de sindrome de falla organica multiple; (9) se recomienda la monitorizacion de la presion de perfusion abdominal en casos seleccionados
The objectives of the study were to assess organ dysfunction in burn patients by using the Sequen... more The objectives of the study were to assess organ dysfunction in burn patients by using the Sequential Organ Failure Assessment (SOFA) score, to determine the relationship between early (day 1) and late (day 4) organ dysfunction, as well as the change in organ dysfunction from admission to day 4, and mortality. The design was a prospective observational cohort study. Patients were admitted to our intensive care burn unit with severe thermal burns (> or =20% total body surface area [BSA] burned) or inhalation injury with a delay from injury to admission less than 12 h and a length of stay less than 3 days (n = 439; age, 46.0 +/- 20.3 yrs; total BSA burned, 31.6% +/- 20.2% [mean +/- SD]; inhalation injury, 44.4%; crude mortality, 18.5%). Sequential Organ Failure Assessment scores were measured on admission (SOFA 0) and on subsequent days (SOFA 1, SOFA 2, SOFA 3, and SOFA 4). The difference between SOFA 0 and SOFA 4 (DeltaSOFA 0-4) was calculated. Multivariate logistic regression analyses, including other variables associated with mortality in the models, were performed to calculate adjusted odds ratios (ORs) of organ dysfunction measurements for mortality. After adjusting for age, BSA burned, diagnosis of inhalation injury, and sex, SOFA 1 (OR, 1.89; 95% confidence interval [CI], 1.55-2.32), SOFA 4 (OR, 1.33; 95% CI, 1.19-1.47), and DeltaSOFA 0-4 (OR, 1.40; 95% CI, 1.28-1.55) were independently associated with mortality. The SOFA score is useful to assess organ dysfunction in burn patients. Burn-induced organ dysfunction (early and late), as well as the change in organ dysfunction, is independently associated with mortality.
To develop a model for predicting mortality among burn victims. All casualties admitted to our in... more To develop a model for predicting mortality among burn victims. All casualties admitted to our intensive care burn unit (ICBU) with a diagnosis of thermal or inhalation injury were studied. Age, total and full-thickness body surface area (BSA) burned, presence of inhalation injury, gender, mechanism of injury, delay to ICBU admission and mechanical ventilation during the first 72 h were recorded. The 851 participants were randomly divided into derivation (671) and validation (180) sets. From univariate and multivariate logistic regression analyses a mortality predictive equation was derived. Mortality was 17.6%. In univariate analysis, all variables were significantly associated with mortality except mechanism of injury and delay to ICBU admission. In multivariate analysis, age, total and full-thickness BSA burned, female gender and early mechanical ventilation were independently associated with mortality. We propose a mortality predictive equation for burned victims. In this model, MV and not inhalation injury is a mortality risk factor.
Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intest... more Splanchnic ischemia is frequent in sepsis and septic shock and is related to impairment in intestinal permeability, derangement in mucosal barrier functions and translocation of proinflammatory mediators. These changes can contribute to the pathogenesis of multiple organ failure. Vasoactive drugs such as dobutamine and dopexamine can improve splanchnic perfusion and gastric intramucosal pH during sepsis. However, contradictory results have been obtained with dopamine and norepinephrine. On the other hand, epinephrine further impairs splanchnic perfusion. In view of the contradictory effects of different vasoactive drugs, gastric tonometry must be measured during their use, to find the optimal drug combination that optimizes splanchnic blood flow.
Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which... more Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile. Methods Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4...
Paciente varón de 20 años, con diagnóstico de asma conocida, llegó al departamento de emergencias... more Paciente varón de 20 años, con diagnóstico de asma conocida, llegó al departamento de emergencias de un hospital de su localidad con historia de disnea 1 d antes de la admisión. Posteriormente, se torna taquicárdico, taquipneico y cianótico, por lo que fue intubado de emergencia. En la UCI del hospital general de tercer nivel, presentó bron- coespasmo grave, presiones de vía aérea elevadas durante la ventilación mecánica e hipoperfusión grave. Recibió cristaloides y norepinefrina como resucitación. Al tercer día, presentó enfsema subcutáneo, neumotórax e hipercapnia con acidosis mixta. Se decidió utilizar ventilación mecánica ultraprotectora asociada con Novalung . Con esta estrategia, logramos reducir las presiones de la vía aérea, la PEEPi, la potencia mecánica (PM) resistiva y mejorar la hipercapnia y la acidosis. El paciente permaneció 10 d en Novalung y mostró buena evolución posterior. Finalmente, es extubado, dado de alta de la UCI y salió del hospital en buenas condiciones.
Uploads
Papers by Vinko Tomicic