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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Investigar en pacientes con traumatismo craneoencef&#225;lico grave y moderado &#40;TCE&#41;&#44; hemodin&#225;micamente estables&#44; la relaci&#243;n entre los valores arteriales de &#225;cido l&#225;ctico &#40;AL&#41; en las primeras 48 horas con la evoluci&#243;n y complicaciones del TCE&#44; y conocer qu&#233; factores de riesgo se relacionan con valores anormales de AL&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; pros-pectivo&#44; de cohorte&#44; de 210 pacientes adultos con TCE grave y moderado&#46; Conseguida la estabilizaci&#243;n hemodin&#225;mica del paciente&#44; se realiz&#243; una determinaci&#243;n basal de AL&#44; que se repiti&#243; cada 12 horas durante las primeras 48 horas y&#44; posteriormente&#44; cada 24 horas hasta la normalizaci&#243;n de los valores de AL&#46; Los pacientes se clasificaron en dos grupos&#58; Grupo 1 &#40;AL &#60; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; sin hipoperfusi&#243;n oculta &#40;HO&#41;&#44; y grupo 2 &#40;AL &#8805; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; con HO&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">115 pacientes &#40;57&#44;76&#37;&#41; se catalogaron como grupo 1&#44; y 95 pacientes &#40;45&#44;24&#37;&#41; como grupo 2&#46; En el an&#225;lisis univariante de los factores de riesgo para AL &#8805; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L mostraron significaci&#243;n estad&#237;stica todos los &#237;ndices generales de gravedad del TCE &#91;Glasgow Coma Scale &#40;GCS&#41;&#44; Injury Severity Score &#40;ISS&#41;&#44; Trauma Score Revisado &#40;TSR&#41; y Acute Physiology and Chronic Health Evaluation &#40;APACHE&#41; II&#93;&#44; la hipotensi&#243;n arterial&#44; hipoxemia&#44; anemia&#44; hiper-glucemia&#44; hipotermia y la mayor incidencia de administraci&#243;n de noradrenalina&#46; Asimismo&#44; en el grupo 1 se objetiv&#243; un mayor porcentaje en la TAC de ingreso de lesiones tipo II &#40;53&#44;91&#37; vs&#46; 38&#44;94&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; En el an&#225;lisis multivariante de regresi&#243;n log&#237;stica&#44; s&#243;lo dos factores se asociaron de forma independiente a valores elevados de AL&#58; APACHE II en las primeras 24 horas&#58; OR 1&#44;12 &#40;IC 95&#37; 1&#44;06&#8211;1&#44;196&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; y volumen de l&#237;quidos total infundido en las primeras 48 horas&#58; OR 1&#44;09 &#40;IC 95&#37; 1&#44;02&#8211;1&#44;16&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; El grupo 2 se asoci&#243;&#44; con significaci&#243;n estad&#237;stica&#44; a una mayor tasa de infecciones &#40;63&#44;2&#37; vs 47&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#44; y al aumento de la estancia en UCI&#46; &#91;mediana &#40;percentil 25&#8211;75&#41;&#93; &#91;13&#44;29 &#40;7&#44;11&#8211;21&#44;22&#41; d&#237;as vs&#46; 8&#44;78 &#40;4&#44;40&#8211;16&#44;72&#41; d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#93;&#46; Aunque fue m&#225;s alto el porcentaje de hipertensi&#243;n intracraneal y mortalidad en el grupo 2&#44; no se constat&#243; significaci&#243;n estad&#237;stica&#46; El aumento de AL&#44; en el an&#225;lisis multivariante&#44; no se comport&#243; como factor independiente de riesgo para las complicaciones estudiadas&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La existencia de HO en pacientes con TCE graves y moderados&#44; con valores de presi&#243;n arterial postreanimaci&#243;n seg&#250;n las recomendaciones actuales&#44; se asocia a una mayor gravedad del TCE manifestada por el APACHE II y por el volumen de l&#237;quidos administrado en las primeras 48 horas&#46; La HO en el TCE conlleva un aumento de la tasa de infecciones y de la estancia en UCI&#46;</p>"
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        "titulo" => "Summary"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To determine the correlation between blood lactic acid levels in the first48 hours and outcome&#44; in hemodynamically stable patients&#44; with moderate or severe head injury &#40;HI&#41;&#44; and to investigate the risk factors associated with abnormal lactate levels&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study&#44; in 210 adults patients with moderate or severe head injury&#46; When the patients were hemodynamically stable&#44; blood lactate concentrations were measured once on admission&#44; twice daily during the first 2 days and once daily until lactate levels were normalized&#46; The whole group 210 patients were divided into 2 groups&#46; Group 1&#58; &#40;LA &#60; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; patients without occult hypoperfussion &#40;OH&#41;&#44; and group 2&#58; &#40;LA &#8805; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41; patients with OH&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">One hundred and fifteen patients &#40;57&#44;76&#37;&#41; were categorized as group 1&#44; and 95 patients &#40;45&#44;24&#37;&#41; as group 2&#46; In the univariate analysis of risk factors for blood lactate &#8805; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L the following variables showed statistical significance&#58; severity of the head injury measured by several scales &#91;Glasgow Coma Scale &#40;GCS&#41;&#44; Injury Severity Score &#40;ISS&#41;&#44; Revised Trauma Score &#40;RTS&#41; and Acute Physiology and Chronic Health Evaluation &#40;APACHE&#41; II&#93;&#44; arterial hypotension&#44; hypoxemia&#44; anaemia&#44; hyperglucemia&#44; hypothermia&#44; a greater incidence of norepinephrine infusion&#44; and the higher percentage of type II lesions in the head computerized tomography at admission showed in the group 1 &#40;53&#44;91&#37; vs&#46; 38&#44;94&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; In the multiple logistic regression analysis only two variables were risk independently associated with elevated blood lactate concentration&#58; APACHE II in the first 24 hours&#58; OR 1&#44;12 &#40;95&#37; IC 1&#44;06&#8211;1&#44;196&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; and the first 48-hours total fluid infusion volumes&#58; OR 1&#44;09 &#40;95&#37; IC 1&#44;021&#44;16&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; The infection rate &#40;63&#44;2&#37; vs 47&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#44; and length of ICU stay &#91;mediana &#40;percentil 25&#8211;75&#41;&#93; &#91;13&#44;29 &#40;7&#44;11&#8211;21&#44;22&#41; days vs&#46; 8&#44;78 &#40;4&#44;40&#8211;16&#44;72&#41; days&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#93; were significantly higher in patients with blood lactate &#8805; 2&#44;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L &#40;group 2&#41;&#46; Although&#44; the percentage of intracranial hypertension and mortality was higher in the group 2&#44; there was no significant difference&#46; In the multivariate analysis&#44; the increase of blood lactate concentration&#44; was not independently associated as a risk factor with studied complications&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The presence of OH in patients with moderate or severe head injury&#44; with postres uscitation arterial pressure&#44; according to present recommendations&#44; is associated with a more severe head injury&#44; showed by APACHE II and the total fluid infusion volumes in the first 48 hours&#46; OH in head injury increases the infection rate and length of ICU stay&#46;</p>"
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Vol. 16. Núm. 4.
Páginas 323-331 (enero 2004)
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Vol. 16. Núm. 4.
Páginas 323-331 (enero 2004)
Existencia de hipoperfusión oculta sistémica en el traumatismo craneoencefálico. Estudio preliminar
Evidence of occult systemic hypoperfussion in head injured patients. Preliminary study
Visitas
1703
F. Murillo-Cabezas
, R. Amaya-Villar, Mª.D. Rincón-Ferrari, J.M. Flores-Cordero, S. García-Gómez, Mª.A. Muñoz-Sánchez
Servicio de Cuidados Críticos y Urgencias. Hospitales Universitarios Virgen del Rocío. Sevilla
J. Valencia-Anguita*
* Servicio de Neurocirugía. Hospitales Universitarios Virgen del Rocío. Sevilla
Este artículo ha recibido
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Resumen
Objetivos

Investigar en pacientes con traumatismo craneoencefálico grave y moderado (TCE), hemodinámicamente estables, la relación entre los valores arteriales de ácido láctico (AL) en las primeras 48 horas con la evolución y complicaciones del TCE, y conocer qué factores de riesgo se relacionan con valores anormales de AL.

Material y métodos

Estudio observacional, pros-pectivo, de cohorte, de 210 pacientes adultos con TCE grave y moderado. Conseguida la estabilización hemodinámica del paciente, se realizó una determinación basal de AL, que se repitió cada 12 horas durante las primeras 48 horas y, posteriormente, cada 24 horas hasta la normalización de los valores de AL. Los pacientes se clasificaron en dos grupos: Grupo 1 (AL < 2,2mmol/L) sin hipoperfusión oculta (HO), y grupo 2 (AL ≥ 2,2mmol/L) con HO.

Resultados

115 pacientes (57,76%) se catalogaron como grupo 1, y 95 pacientes (45,24%) como grupo 2. En el análisis univariante de los factores de riesgo para AL ≥ 2,2mmol/L mostraron significación estadística todos los índices generales de gravedad del TCE [Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Trauma Score Revisado (TSR) y Acute Physiology and Chronic Health Evaluation (APACHE) II], la hipotensión arterial, hipoxemia, anemia, hiper-glucemia, hipotermia y la mayor incidencia de administración de noradrenalina. Asimismo, en el grupo 1 se objetivó un mayor porcentaje en la TAC de ingreso de lesiones tipo II (53,91% vs. 38,94%) (p<0,03). En el análisis multivariante de regresión logística, sólo dos factores se asociaron de forma independiente a valores elevados de AL: APACHE II en las primeras 24 horas: OR 1,12 (IC 95% 1,06–1,196; p<0,0001) y volumen de líquidos total infundido en las primeras 48 horas: OR 1,09 (IC 95% 1,02–1,16; p<0,0001). El grupo 2 se asoció, con significación estadística, a una mayor tasa de infecciones (63,2% vs 47,8%, p=0,026), y al aumento de la estancia en UCI. [mediana (percentil 25–75)] [13,29 (7,11–21,22) días vs. 8,78 (4,40–16,72) días; p<0,018]. Aunque fue más alto el porcentaje de hipertensión intracraneal y mortalidad en el grupo 2, no se constató significación estadística. El aumento de AL, en el análisis multivariante, no se comportó como factor independiente de riesgo para las complicaciones estudiadas.

Conclusiones

La existencia de HO en pacientes con TCE graves y moderados, con valores de presión arterial postreanimación según las recomendaciones actuales, se asocia a una mayor gravedad del TCE manifestada por el APACHE II y por el volumen de líquidos administrado en las primeras 48 horas. La HO en el TCE conlleva un aumento de la tasa de infecciones y de la estancia en UCI.

Palabras clave:
Traumatismo craneoencefálico
Acido láctico
Hipoperfusión oculta
Deuda de oxígeno
Abreviaturas:
AIS
AL
APACHE II
GCS
HO
ICU
ISS
LA
OH
RTS
SDRA
TAC
TCE
TSR
UCI
Summary
Objectives

To determine the correlation between blood lactic acid levels in the first48 hours and outcome, in hemodynamically stable patients, with moderate or severe head injury (HI), and to investigate the risk factors associated with abnormal lactate levels.

Material and methods

A prospective observational study, in 210 adults patients with moderate or severe head injury. When the patients were hemodynamically stable, blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily until lactate levels were normalized. The whole group 210 patients were divided into 2 groups. Group 1: (LA < 2,2mmol/L) patients without occult hypoperfussion (OH), and group 2: (LA ≥ 2,2mmol/L) patients with OH.

Results

One hundred and fifteen patients (57,76%) were categorized as group 1, and 95 patients (45,24%) as group 2. In the univariate analysis of risk factors for blood lactate ≥ 2,2mmol/L the following variables showed statistical significance: severity of the head injury measured by several scales [Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS) and Acute Physiology and Chronic Health Evaluation (APACHE) II], arterial hypotension, hypoxemia, anaemia, hyperglucemia, hypothermia, a greater incidence of norepinephrine infusion, and the higher percentage of type II lesions in the head computerized tomography at admission showed in the group 1 (53,91% vs. 38,94%) (p<0,03). In the multiple logistic regression analysis only two variables were risk independently associated with elevated blood lactate concentration: APACHE II in the first 24 hours: OR 1,12 (95% IC 1,06–1,196; p<0,0001) and the first 48-hours total fluid infusion volumes: OR 1,09 (95% IC 1,021,16; p<0,0001). The infection rate (63,2% vs 47,8%, p=0,026), and length of ICU stay [mediana (percentil 25–75)] [13,29 (7,11–21,22) days vs. 8,78 (4,40–16,72) days; p<0,018] were significantly higher in patients with blood lactate ≥ 2,2mmol/L (group 2). Although, the percentage of intracranial hypertension and mortality was higher in the group 2, there was no significant difference. In the multivariate analysis, the increase of blood lactate concentration, was not independently associated as a risk factor with studied complications.

Conclusions

The presence of OH in patients with moderate or severe head injury, with postres uscitation arterial pressure, according to present recommendations, is associated with a more severe head injury, showed by APACHE II and the total fluid infusion volumes in the first 48 hours. OH in head injury increases the infection rate and length of ICU stay.

Keywords:
Head Injury
Lactic Acid.
Occult hypoperfussion
Oxygen Debt

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