Multivessel spontaneous coronary arterial dissection. Usefulness of angio-CT during follow-up


Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of myocardial ischemia associated with a high mortality rate. Its aetiology, incidence and pathogenesis are still unknown. It is characterized by the presence of a hematoma and/or the separation of the different layers in the arterial wall, causing vessel lumen stenosis. The clinical manifestation depends on the extent and limitation of the blood flow caused by the dissection, and it varies from an asymptomatic presentation to acute myocardial infarction (50-75%), sudden cardiac death (0.5%) or heart failure.

Authors: JF Garrido Peñalver, JH de Gea García, R. Jara Rubio, E. Pinar Bermúdez, JI Pascual de la Parte, S. Sánchez Cámara

The optimal ICU organizational structure

A variety of intensive care units (ICU) staffing models exist, which to a large extent are based on local practice and economic factors rather than cost-effectiveness and the quality of care delivered. The organizational structure of ICU in the United States are usually classified according to two types of models, namely a low- or high intensity model, or an open- or closed ICU model. (1,2) In a low-intensity ICU, patients are managed by non-intensivists, however an intensivist may be consulted on some cases (open model), whereas in a high-intensity model intensivists are consulted on all patients (open model) or the intensivist assumes responsibility for the patient and directs all aspects of the care (closed model). The closed ICU structure is the predominant model in almost all Western nations. (3,4) There are significant organizational differences between open and closed ICU. Open units are those in which admission of patients to the ICU is uncontrolled and management of the patients is at the discretion of each attending physician (not an intensivist). Admissions are based on a first-come, first-served basis. As the attending of record does not have the time nor skills to provide “comprehensive critical care” he/she "portions off" the patients' care to a number of organ specific sub-specialists.

Authors: Paul E. Marik, Joseph Varon

Diagnosis and treatment of infective endocarditis in intensive care


Infective endocarditis (IE) is an infectious microbial disease of the heart valvular endothelium. The characteristic lesion consists of the presence of vegetations that can settle in the valvular veils, tendon cords or mural endocardium.

Hospital mortality in patients with severe sepsis or septic shock has been between 20 and 50%, a fact probably underestimated and overshadowed by a late referral to the intensive care unit, even though clear criteria for entry into the unit have been established for patients with this situation.

The objective of this study was to know the characteristics, evolution and prognosis of patients with infective endocarditis who required treatment in the Intensive Care Unit.

Authors: Jesús Cobo Molinos

Airway pressure release ventilation: translating clinical research to the bedside in acute respiratory distress syndrome

Since its birth in the mid eighties of the last century, airway pressure release ventilation (APRV) has been a victim of much debate about its clinical use, benefits, and possible harms. With growing body of literature and evidence, APRV is gaining more acceptance and enthusiasm. Interesting research has been conducted in regards to its benefits in prevention of acute respiratory distress syndrome (ARDS), reduction of extra vascular lung water (EVLW), reduction in ventilator-induced lung injury (VILI), reduction of dead space, weaning off mechanical ventilation, improvement of hemodynamics, improvement in oxygenation, impact on mortality, its use as a non-invasive mode of ventilation, and its role in improving lung procurement for transplantation. The research and clinical application has expanded beyond the adult patients to include critically ill pediatric patients and critically ill animals. This article will review some of the plethora of research done in an attempt to promote its implementation to the bedside.

Airway pressure release ventilation- translating clinical research to the bedside in acute respiratory distress syndrome


How to initiate noninvasive ventilation program in your hospital

Noninvasive ventilation (NIV) is increasingly being employed in the management of acute respiratory failure associated with a number of disease states. However, while there is strong evidence from randomized trials supporting its routine use in the intensive care units (ICU), the task of integrating NIV into standard practice remains a challenging one. In this article, we discuss different considerations surrounding NIV incorporation into hospitals’ standard programs for managing acute respiratory distress. We also outline the important factors crucial for setting up an NIV program and diffusing its operation and the derivable benefits into a clinic’s respiratory care management system. It is important that the NIV diffusion process is anchored on the experience of a clinical champion, an early adopter and opinion leader who is effective in communicating the benefits of noninvasive mechanical ventilation methods to other clinicians.


Ethambutol-induced nephrotoxicity: case report and review of the literature

Ethambutol is a common component in the treatment of mycobacteria infections worldwide, and is rarely associated with nephrotoxicity. We report a patient presenting with acute kidney injury due to ethambutol as well as its management and a comprehensive review of the pertinent literature.Ethambutol-induced nephrotoxicity- case report and review of the literature


Clinical application, the use of dexmedetomidine in intensive care sedation

Sedation and analgesia are common interventions in intensive care and constitute an integral part of the care of critically ill patients. However, there is no consensus on the best combination of agents or strategies to manage sedation and analgesia effectively and safely, and in particular in patients who need prolonged mechanical ventilation.
The current Clinical Practice Guidelines for the provision of sedation and analgesia in critically ill adults were drafted in 2002 and are supported by studies that largely apply to a North American practice of intensive care rather than an Australasian practice. (1) Benzodiazepines and other gamma-aminobutyric acid (GABA)


The Use of APRV and Open Lung Management for Improving the Outcome of Lung Procurement for Transplantation

One of the most difficult organs to procure for donation is the lung. A detailed understanding of the physiology of mechanical ventilation and its effect on donor lungs is needed to impact on the outcome of lung transplantation. An organized protocol for mechanical ventilation management of the organ donor using the Open Lung Model may positively affect the number of organs that can be procured, and the function of these organs post transplant.
Based on physiologic principles, the use of new modes of ventilation may affect the modulation of cytokines, decrease the transmigration of organisms into the donor lung, ...


Critical Care Economics

Health care costs represent a large percentage of the gross domestic product all over the world. According to the National Health Statistics Group, health care expenditure in the United States accounted for as much as 14% of the gross national product in 1992 and it is projected to reach 30% by 2030.
The intensive care unit (ICU) represents the hallmark of highly competent modern hospitals, offering highly trained staff and life-saving technology and it is also one of the most expensive units in the hospital.
Expenses related to running the ICU have been estimated at approximately 20% of total hospital costs, despite only representing 10% of all hospital beds.
Assisted mechanical ventilation particularly affects the high costs in the ICU. Actually, a mere of 1 million persons per year receive mechanical ventilation during their stay in the ICU. A variety of different approaches to stabilize or reduce costs in ...


Exercise-Associated Hyponatremia and the Varon-Ayus Syndrome

Endurance sports such as marathon running are increasingly popular, attracting both professional and recreational athletes. While most participants recognize that these events can result in health hazards, few consider death a likely outcome. Exercise associated hyponatremia can be a consequence for which fatal outcomes may occur. In some it is mild and without symptoms. However, in others it is of such severity that respiratory failure secondary to pulmonary edema, and possibly death may result. This article reviews new information regarding predisposing factors, treatment, and outcomes associated with exercise induced hyponatremia and the Varon-Ayus syndrome (hyponatremia, pulmonary edema and cerebral edema associated to marathon running).