Papers by JOEL JAVIER VARGAS HERNANDEZ
Acid-base Acidemia Alkalemia Anion gap Delta gap Osmol gap Toxicity
La vida de los animales superiores depende de la obtención de energía indispensable para mantener... more La vida de los animales superiores depende de la obtención de energía indispensable para mantener la integridad de las complejas estructuras que mantienen la vida en contra de la constante tendencia a la entropía presente en todo sistema organizado. El sistema más eficiente para obtener energía utiliza el oxígeno en la cadena respiratoria. El oxígeno es un poderoso aceptor de electrones y su presencia al final de la vía de la fosforilación oxidativa es indispensable para que los electrones, ya liberados de su energía útil, salgan del sistema de transporte y acoplamiento y su lugar pueda ser ocupado por nuevos electrones activados. El oxígeno forma agua con los protones que acompañan a los electrones ya desactivados. En ausencia de oxígeno, la cadena respiratoria queda bloqueada por electrones desactivados y la obtención de energía para suplir las necesidades metabólicas debe hacerse apelando a sistemas evolutivamente menos desarrollados y energéticamente menos eficientes, especialmente a la glucólisis anaerobia (equivalente a los procesos de fermentación mediante los cuales obtienen energía los microorganismos más primitivos). Este proceso de glucólisis anaerobia permite degradar glucosa en ausencia de oxígeno hasta ácido láctico liberando energía suficiente para crear dos enlaces macroérgicos que permiten trasformar dos moles de ADP en dos moles de ATP . Para dejar sentada la importancia del oxígeno para la vida desde el punto de vista termodinámico, baste recordar que la oxidación anaerobia de una mol de glucosa hasta dos moles de lactato permite el almacenamiento de energía en dos moles de ATP , mientras que la oxidación aerobia de una mol de glucosa hasta seis moles de agua y seis moles de bióxido de carbono permite el almacenamiento de energía en 38 moles de ATP . A diferencia de los metabolitos utilizados como fuente de energía, que pueden ser almacenados de diversas maneras en el interior celular, el oxígeno indispensable para la respiración aerobia no puede ser almacenado y, sin embargo, tiene que estar permanentemente a disposición de la célula. Esta circunstancia hace que el oxígeno sea el principal factor limitante para la obtención de energía en las formas de vida más evolucionadas y hace también que sea el factor determinante en el mantenimiento inmediato de la integridad de los complejísimos sistemas y estructuras vitales de dichos organismos en continuo combate contra la entropía.
Increased understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in th... more Increased understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. This review addresses the many systemic complications of TBI that make achieving these targets challenging and can influence outcome.
Severe sepsis is the trigger for the development of approximately 50% of cases of acute kidney in... more Severe sepsis is the trigger for the development of approximately 50% of cases of acute kidney injury (AKI) among critically ill patients. 1 Even in patients with less severe infections, the incidence of AKI is as high as 16% to 25%. 2 Sepsis-induced AKI is associated with mortality rates of up to 50% to 60%, depending on severity. 3 Septic AKI is characterized by a rapid and often profound decline in the kidneys' ability to filter blood and eliminate nitrogen waste products, usually evolving over hours to days after the onset of sepsis. 4 Limited understanding of pathophysiologic mechanisms has precluded the development of effective therapies for sepsis-induced AKI. However, Conflicts of Interest: None declared.
Pulse oximetry is universally used for monitoring patients in the critical care setting. This art... more Pulse oximetry is universally used for monitoring patients in the critical care setting. This article updates the review on pulse oximetry that was published in 1999 in Critical Care. A summary of the recently developed multiwavelength pulse oximeters and their ability in detecting dyshemoglobins is provided. The impact of the latest signal processing techniques and reflectance technology on improving the performance of pulse oximeters during motion artifact and low perfusion conditions is critically examined. Finally, data regarding the effect of pulse oximetry on patient outcome are discussed.
Hospital-acquired pneumonia (HAP) Ventilator-associated pneumonia (VAP) Pulmonary Aspiration Infe... more Hospital-acquired pneumonia (HAP) Ventilator-associated pneumonia (VAP) Pulmonary Aspiration Infection
Cómo citar este artículo: Latour-Pérez J. Nuevas recomendaciones sobre la utilización de solucion... more Cómo citar este artículo: Latour-Pérez J. Nuevas recomendaciones sobre la utilización de soluciones de albúmina humana en pacientes con sepsis grave y shock séptico. Una evaluación crítica de la literatura. Med Intensiva. 2013. http://dx.
Introduction: Nebulized antibiotics are a promising new treatment option for ventilator-associate... more Introduction: Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia. However, more evidence of the benefit of this therapy is required.
The results of recent large-scale clinical trials have led us to review our understanding of the ... more The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.
BACKGROUND—The goal of mechanical ventilation in acute hypoxemic respiratory failure is to suppor... more BACKGROUND—The goal of mechanical ventilation in acute hypoxemic respiratory failure is to support adequate gas exchange without harming the lungs. How patients are mechanically ventilated can significantly impact their ultimate outcomes.
A substantial number of patients admitted to the ICU because of an acute illness, complicated sur... more A substantial number of patients admitted to the ICU because of an acute illness, complicated surgery, severe trauma, or burn injury will develop a de novo form of muscle weakness during the ICU stay that is referred to as " intensive care unit acquired weakness " (ICUAW). This ICUAW evoked by critical illness can be due to axonal neuropathy, primary myopathy, or both. Underlying pathophysiological mechanisms comprise microvascular, electrical, metabolic, and bioenergetic alterations, interacting in a complex way and culminating in loss of muscle strength and/or muscle atrophy. ICUAW is typically symmetrical and affects predominantly proximal limb muscles and respiratory muscles, whereas facial and ocular muscles are often spared. The main risk factors for ICUAW include high severity of illness upon admission, sepsis, multiple organ failure, prolonged immobilization, and hyperglycemia, and also older patients have a higher risk. The role of corticosteroids and neuromuscular blocking agents remains unclear. ICUAW is diagnosed in awake and cooperative patients by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score. In cases of atypical clinical presentation or evolution, additional electrophysiological testing may be required for differential diagnosis. The cornerstones of prevention are aggressive treatment of sepsis, early mobilization, preventing hyperglycemia with insulin, and avoiding the use parenteral nutrition during the first week of critical illness. Weak patients clearly have worse acute outcomes and consume more healthcare resources. Recovery usually occurs within weeks or months, although it may be incomplete with weakness persisting up to 2 years after ICU discharge. Prognosis appears compromised when the cause of ICUAW involves critical illness polyneuropathy, whereas isolated critical illness myopathy may have a better prognosis. In addition, ICUAW has shown to contribute to the risk of 1-year mortality. Future research should focus on new preventive and/or therapeutic strategies for this detrimental complication of critical illness and on clarifying how ICUAW contributes to poor longer-term prognosis.
Introduction: Use of hydroxyethyl starch (HES) in septic patients is reported to increase the mor... more Introduction: Use of hydroxyethyl starch (HES) in septic patients is reported to increase the mortality and incidence of renal replacement therapy (RRT). However, whether or not use of HES would induce the same result in non-septic patients in the intensive care unit (ICU) remains unclear. The objective of this meta-analysis was to evaluate 6% HES versus other fluids for non-septic ICU patients.
herr, avery tunG, BryCe r. h. roBinson, Dorrie K. Fontaine, MiChael a. raMsay, riCharD r. riKer, ... more herr, avery tunG, BryCe r. h. roBinson, Dorrie K. Fontaine, MiChael a. raMsay, riCharD r. riKer, Curtis n. sessler, BrenDa Pun, yoanna sKroBiK, anD roMan JaesChKe
Ants, bees, and ancient physicians recognized a sweet taste in the urine of individuals afflicted... more Ants, bees, and ancient physicians recognized a sweet taste in the urine of individuals afflicted by a condition of polyuria and wasting. With the attachment of the Latin term, mellitus, diabetes was forever linked to a disorder of glucose metabolism. Although many other metabolic abnormalities exist in diabetes, its diagnosis and, to a large degree, its management are unified through the presence of hyperglycemia. In 1943, Dr Eliot Joslin 1 observed that life expectancy after the onset of diabetes had increased from less than 5 years to greater than 14 years with the introduction of insulin therapy, and more patients were living long enough to suffer from its complications. These complications have been divided into 2 general categories: (1) microvas-cular: retinopathy, nephropathy, and neuropathy; and (2) macrovascular, affecting the coronary, cerebral, and peripheral vascular systems. The central question is whether the obvious abnormality of diabetes (ie, hyperglycemia) is responsible for these complications. This is the basis of the glucose hypothesis: that hyperglycemia is their direct cause and that, by normalizing systemic glucose levels, these morbidities can be prevented. The available evidence supports targeting near-normal glucose levels for the prevention and reduction of the microvascular complications of diabetes. Although there is a strong relationship between glucose levels and macrovascular disease in diabetes, the evidence for preventing and reducing the macrovascular complications of diabetes by glucose lowering is limited. Glycemic targets must be individualized and based on patient specific factors that balance the benefits of therapy with its harms.
El pie diabético (PD) es una complicación crónica de la DM, con etiología multifactorial, teniend... more El pie diabético (PD) es una complicación crónica de la DM, con etiología multifactorial, teniendo como factores principales la infección, isquemia, neuropatía y mal control metabólico. Tiene características clínicas frecuentes como úlceras, gangrenas y amputaciones en las extremidades inferiores, ocasionando en el paciente discapacidad parcial o definitiva. 1-3 Los pacientes con este problema de salud deben ingresar a un programa de PD que debe ser permanente, estratégico y multidisciplinario incluyendo la prevención y el tratamiento del PD. Nosotros hemos implementado un programa de PD que hasta la fecha tiene doce años de funcionamiento y se han evaluado aproximadamente cinco mil pacientes. En dicho programa, se han realizado estudios de investigación publicados 5,6 y presentados en congresos internacionales de DM. 7-12
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Papers by JOEL JAVIER VARGAS HERNANDEZ