J Homar

Hospital Universitari Son Espases, Palma, Balearic Islands, Spain

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Publications (25)46.09 Total impact

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    ABSTRACT: Multiorgan failure remains one of the leading causes of late morbidity and mortality after severe trauma. In the early phase, it is related with an uncontrolled hyper-inflammation state, whereas in the late phase (>72h), septic complications play a major role. We review the underlying pathophysiology, the evaluation with different scales and the clinical factors associated with multiorgan failure, as well as potential treatment options.
    Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias. 07/2014;
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    ABSTRACT: Multiorgan failure remains one of the leading causes of late morbidity and mortality after severe trauma. In the early phase, it is related with an uncontrolled hyper-inflammation state, whereas in the late phase (> 72 h), septic complications play a major role. We review the underlying pathophysiology, the evaluation with different scales and the clinical factors associated with multiorgan failure, as well as potential treatment options.
    Medicina Intensiva 01/2014; · 1.32 Impact Factor
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    ABSTRACT: The diagnosis of brain death remains a clinical challenge for intensive care unit physicians. Worldwide regulations in its diagnosis may differ, and the need of ancillary tests after a clinical examination is not uniform. Transcranial sonography is a noninvasive, bedside, and widely available technique that can be used in the diagnosis of the cerebral circulatory arrest that preceeds brain death. In this paper we review the general concepts, the technical requisites, the patterns of Doppler signal confirming cerebral circulatory arrest, the vessels to insonate, and the options in cases with poor acoustic window. Future research perspectives in the field of transcranial sonography are discussed as well.
    ISRN Critical Care. 10/2012; 2013.
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    ABSTRACT: To determine the evolution of cytokine patterns using microdialysis in patients with traumatic brain injury with diffuse lesions and to study the relationship between cytokines and intracranial pressure, brain tissue oxygenation and lesion type on the computed cranial tomography scan (patients with and without brain swelling). Prospective and observational study. Third-level university hospital. Patients between 15 and 65 yrs with severe traumatic brain injury and a diffuse lesion requiring intracranial pressure and brain tissue oxygenation monitoring were eligible. Microdialysis catheters with a high-cutoff membrane of 100 kDa were inserted. Sixteen patients were included in the analysis. There was a substantial interindividual variability between cytokine values. The highest concentrations for the interleukin-1β, interleukin-6, and interleukin-8 were measured during the first 24 hrs followed by a gradual decline. The average concentration for interleukin-10 did not vary over time. This pattern is the most frequent in patients with traumatic brain injury with diffuse lesions. The intracranial pressure-cytokines correlation coefficients for the 16 patients varied substantially: interleukin-1β-intracranial pressure (-0.76 to 0.63); interleukin-6-intracranial pressure (-0.83 to 0.78); interleukin-8-intracranial pressure (-0.86 to 0.84); and interleukin-10-intracranial pressure (-0.36 to 0.65). The brain tissue oxygenation-cytokine correlation coefficients, like with intracranial pressure, also varied between patients: interleukin-1β-brain tissue oxygenation (-0.49 to 0.68), interleukin-6-brain tissue oxygenation (-0.99 to 0.84); interleukin-8-brain tissue oxygenation (-0.65 to 0.74); and interleukin-10-brain tissue oxygenation (-0.34 to 0.52). Similarly, we found no difference in the cytokine values inpatient microdialysis with and without swelling in the computed tomographic scan. No clear relationship was found between the temporal pattern of cytokines and the behavior of the intracranial pressure, brain tissue oxygenation, and the presence or absence of swelling in the computed tomography scan. This study demonstrates the feasibility of microdialysis in recovering cytokines for a prolonged time, although there may be some nonresolved methodologic problems with this technique when we try to study the inflammation during traumatic brain injury that could affect the results and make interpretation of microdialysis data prone to difficulties.
    Critical care medicine 03/2011; 39(3):533-40. · 6.37 Impact Factor
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    ABSTRACT: Drainage of cerebrospinal fluid by means of external lumbar drainage (ELD) is controversial in the adult population with traumatic brain injury. We report our experience with ELD in the treatment of post-traumatic high intracranial pressure (ICP) and the results of the long-term follow-up in these patients. We undertook clinical evaluation of 30 patients with traumatic brain injury and high ICP treated with second-tier measures or with first-tier measures if second-tier measures were contraindicated. The study involved a retrospective review of collected data. Outcome at intensive care unit discharge and three to five years after injury were evaluated with the Glasgow Outcome Scale. The mean age of patients was 34.9 +/- 12.5 years and 25 (83%) were male. The median (interquartile range) Glasgow Coma score was 8 (7 to 10). ICP before and one hour after ELD placement was 33.7 +/- 9.0 and 12.5 +/- 4.8 mmHg respectively, a decrease in 21.2 +/- 8.3 mmHg (P < 0.0001). ELD was placed after a mean of 8.6 +/- 3.9 days. Cerebrospinal fluid drainage was maintained for a mean of 6.6 +/- 3.5 days. Four patients (13%) required ELD replacement and one patient developed a cerebrospinal fluid infection (3%). No pupillary changes were noted within 48 hours of ELD placement. Long-term outcome was favourable (good recovery or moderate disability) in 62% of the patients studied. The use of ELD resulted in a marked decrease in ICP These patients presented a good outcome in 62% of the cases in the long-term evaluation. Few complications related with ELD use were noted.
    Anaesthesia and intensive care 01/2011; 39(1):79-83. · 1.40 Impact Factor
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    ABSTRACT: Traumatic brain injury (TBI) is commonly associated with disturbances of the hypothalamic-pituitary-adrenal axis secretion. Cerebral microdialysis techniques have been recently applied to measure brain interstitial cortisol levels. We evaluated for the first time the circadian rhythm of cortisol secretion at 08:00, 16:00, and 24:00 h in the acute phase of TBI by determination of total serum and brain interstitial cortisol levels (microdialysis samples) in 10 patients with TBI. Non-parametric Friedman's two way analysis of variance test was used. Mean age was 29.8 ± 13.6 years. Median Glasgow Coma Scale score after resuscitation was 5 (range 3-10). No differences were found in total serum (P = 0.26) and brain interstitial cortisol (P = 0.77) in the whole sample. Intraindividual analysis showed that circadian variability was lost in all patients, both in serum and brain interstitial cortisol samples in the acute phase after TBI. In our series, circadian variability of cortisol evaluated by serum and cerebral microdialysis samples seems to be lost in TBI patients.
    Neurocritical Care 10/2010; 13(2):211-6. · 3.04 Impact Factor
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    ABSTRACT: Brain cortisol availability has never been evaluated in patients with traumatic brain injury (TBI). Cerebral microdialysis is a well-established technique for monitoring brain metabolism in neurocritically ill patients, which may be used to measure interstitial cortisol. The objective of this preliminary study was to measure brain interstitial cortisol and its correlation with total serum cortisol in patients with TBI. We prospectively studied 6 patients with severe TBI admitted to the Intensive Care Unit of our tertiary University Hospital in which multimodal neuromonitoring including cerebral microdialysis with a high cut-off of 100 k-Da and 20-mm long membrane was used. Serum and brain interstitial cortisol microdialysis samples were obtained every 8 h and analyzed afterwards. Linear regression analysis of total serum cortisol and brain interstitial cortisol in the whole population showed a moderate correlation (R2=0.538, p<0.001, no.=118). However, intra-individual correlation showed a great variability, with correlation coefficients ranging from a R2=0.091 to R2=0.680. Our prospective and preliminary study showed a moderate correlation of brain interstitial cortisol and total serum cortisol values in patients with diffuse TBI. However, intra-individual analysis showed a great variability. These results suggest that total serum cortisol may not reflect brain cortisol availability in half of TBI patients.
    Journal of endocrinological investigation 06/2010; 33(6):368-72. · 1.65 Impact Factor
  • Journal of Neurosurgery 12/2009; 111(6):1295; author reply 1295-6. · 3.15 Impact Factor
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    ABSTRACT: We sought to determine the utility of constrat-enhanced transcranial color sonography (TCCS) in the diagnosis of cerebral circulatory arrest in cases of difficult acoustic window. From January 2007 to July 2008, we prospectively studied 50 patients who fulfilled clinical criteria of brain death. In all cases, we performed TCCS aiming to insonate both middle cerebral arteries (MCA) and the basilar artery (BA). In those case in which insonation of any vessel was not possible, we repeated the exploration after injecting a 2.5-mL bolus of sulphurhexafluoridedispersion. Afterward, we compared the rate of insonation of the vessels and the number of conclusive studies. The mean patient age was 53.2 +/- 15.9 years. Thirty-two were men (64%). The most frequent neurologic injury was hemorrhagic stroke and traumatic brain injury. Contrast-enhanced TCCS resulted in an increased rate of insonation in both MCA and in BA, and in the number of conclusive studies. Contrast-enhanced TCCS increased the number of conclusive studies with cerebral circulatory arrest, which minimized the importance of a previous study in cases with a poor acoustic window.
    Transplantation Proceedings 07/2009; 41(5):1466-8. · 0.95 Impact Factor
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    ABSTRACT: To evaluate the feasibility, safety and effectiveness of a new method of intravascular temperature management for inducing moderate hypothermia (MHT). Prospective, international-multicenter clinical trial conducted in four university hospitals. In a 2-year period 24 patients with severe head injury and refractory high ICP were treated with MHT (32.5 degrees C) by intravascular methods. Seventeen were males and seven females, with a median age of 25 years (range 15-60). The median Glasgow Coma Scale upon admission was 7 (range 3-13) and the median Injury Severity Score was 22 (range 13-43). A total of 75% of patients presented a diffuse lesion in the pre-enrollment computed tomography. Median time from injury until reaching refractory high ICP was 71.5 h after injury (minimum 14 h, maximum 251 h). Twelve patients (50%) reached this situation within the first 72 h after injury. MHT was attained in a median time of 3 h. Pre-enrollment median ICP was 23.8 mmHg and was reduced to 16.8 mmHg upon reaching target temperature. At 6 months after injury, nine patients had died (37.5%), six were severely disabled (25%), two moderately disabled (8.3%) and seven had a good recovery (29.2%). Of the nine patients who died, in four the cause was rebound ICP during rewarming, one death was attributed to accidental potassium overload, two to septic shock, one to cardiac arrest of unknown origin and the ninth to a pulmonary embolism. Intravascular methods to induce MHT combined with precooling with cold saline at 4 degrees C appear to be feasible and effective in reducing ICP in patients with high ICP refractory to first-line therapeutic measures.
    European Journal of Intensive Care Medicine 12/2008; 35(5):890-8. · 5.17 Impact Factor
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    ABSTRACT: Experimental research has demonstrated that the level of neuroprotection conferred by the various barbiturates is not equal. Until now no controlled studies have been conducted to compare their effectiveness, even though the Brain Trauma Foundation Guidelines recommend that such studies be undertaken. The objectives of the present study were to assess the effectiveness of pentobarbital and thiopental in terms of controlling refractory intracranial hypertension in patients with severe traumatic brain injury, and to evaluate the adverse effects of treatment. This was a prospective, randomized, cohort study comparing two treatments: pentobarbital and thiopental. Patients who had suffered a severe traumatic brain injury (Glasgow Coma Scale score after resuscitation < or = 8 points or neurological deterioration during the first week after trauma) and with refractory intracranial hypertension (intracranial pressure > 20 mmHg) first-tier measures, in accordance with the Brain Trauma Foundation Guidelines. A total of 44 patients (22 in each group) were included over a 5-year period. There were no statistically significant differences in ' baseline characteristics, except for admission computed cranial tomography characteristics, using the Traumatic Coma Data Bank classification. Uncontrollable intracranial pressure occurred in 11 patients (50%) in the thiopental treatment group and in 18 patients (82%) in the pentobarbital group (P = 0.03). Under logistic regression analysis--undertaken in an effort to adjust for the cranial tomography characteristics, which were unfavourable for pentobarbital--thiopental was more effective than pentobarbital in terms of controlling intracranial pressure (odds ratio = 5.1, 95% confidence interval 1.2 to 21.9; P = 0.027). There were no significant differences between the two groups with respect to the incidence of arterial hypotension or infection. Thiopental appeared to be more effective than pentobarbital in controlling intracranial hypertension refractory to first-tier measures. These findings should be interpreted with caution because of the imbalance in cranial tomography characteristics and the different dosages employed in the two arms of the study. The incidence of adverse effects was similar in both groups. (Trial registration: US Clinical Trials registry NCT00622570.).
    Critical care (London, England) 09/2008; 12(4):R112. · 4.72 Impact Factor
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    ABSTRACT: The purpose of this series was to describe the ultrasonographic perfusion pattern in patients with brain death. Thirteen patients with different neurologic disorders in whom brain death developed were studied. Transcranial perfusion was analyzed after injection of 2.5 mL of a sulfur hexafluoride ultrasonographic contrast agent. Time-intensity curves were analyzed in predetermined regions of interest. In all patients, analysis of regions of interest showed no bolus-like curve progression. This finding implies a complete absence of cerebral perfusion. Patients with brain death studied by ultrasonographic perfusion techniques have a characteristic pattern.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 06/2008; 27(5):791-4. · 1.40 Impact Factor
  • European Journal of Anaesthesiology - EUR J ANAESTH. 01/2008; 25:3-4.
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    ABSTRACT: Transcranial sonography is a common tool for monitoring neurocritical patients. Transcranial color-coded duplex ultrasonography enables hemodynamic and structural study of the cerebral parenchyma in these patients. Its advantages over conventional ultrasonography are evident and are derived from direct visualization of the vessel to be studied and appropriate adjustment of the sample volume and angle of insonation. The use of ultrasonographic contrast agents enables conclusive findings in practically 100% of cases and allows cerebral perfusion to be studied at the bedside using semiquantitative methods. This review aims to show the applications of transcranial color-coded duplex ultrasonography for monitoring neurocritical patients in intensive care units.
    Medicina Intensiva 01/2008; 31(9):510-7. · 1.32 Impact Factor
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    ABSTRACT: To compare the number of vessels identified and mean velocity and pulsatility index values obtained by transcranial doppler (TCD) and transcranial color coded sonography (TCCS) in patients with traumatic brain injury (TBI). Thirty patients suffering from TBI admitted in our neurocritical Intensive Care Unit (ICU) were studied. We performed consecutive studies by TCD and TCCS. The number of Circle of Willis vessels insonated and the hemodynamic parameters were compared. Mean age was 50 years. Twenty patients were male. By using TCCS, internal carotid artery was insonated in 95%, middle cerebral artery (MCA) in 95%, anterior cerebral artery (ACA) in 91% and posterior cerebral artery (PCA) in 92% of the studies. Using conventional TCD they were insonated in 29%, 93% 67% and 35% of the studies respectively. Mean velocity values measured by CCS and TCD in MCA were 79 cm/sec vs 59 cm/sec respectively (p< 0.0001), in ACA were 61 cm/sec vs 42 cm/sec (p< 0.0001) and in PCA were 43 cm/sec vs 33 cm/sec (p< 0.0001). TCCS allows a high quality hemodynamic study of TBI patients admitted to the ICU. Further studies must define its impact on outcome of TBI patients.
    Neurocirugia (Asturias, Spain) 07/2007; 18(3):221-6. · 0.34 Impact Factor
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    ABSTRACT: Barbiturate coma is the second tier measure recommended by guidelines to treat post-traumatic refractory intracranial pressure. Systemic hypotension is its most important side effect. Recent evidence suggests that low-dose corticosteroid therapy may be used in a subset of patients with traumatic brain injury (TBI) to avoid hypotension. We evaluated adrenal function in TBI patients undergoing barbiturate coma, as treatment of their refractory intracranial hypertension. We prospectively studied 40 patients with moderate to severe TBI. Group A (17 patients) were treated with barbiturate coma. Group B (23 patients) presented intracranial hypertension controlled with first tier measures, and acted as a control. Adrenal function was evaluated by using the high-dose corticotropin stimulation test within 24 h after brain injury and after barbiturate coma induction. Within 24 h after TBI, adrenal function was similar in both groups. Once barbiturate coma was induced, patients in group A treated with barbiturate coma presented a higher incidence of adrenal insufficiency compared with the control group B (53% vs 22%, p=0.03). Patients treated with barbiturates, who developed adrenal impairment, required higher doses of norepinephrine to maintain cerebral perfusion pressure than patients treated with barbiturates without adrenal impairment (1.07+/-1.04 microg/kg/min vs 0.31+/-0.32 mug/kg/min, p=0.03). Patients with TBI treated with barbiturate coma are at higher risk of developing adrenal insufficiency. This subset of patients presented higher requirements of vasoactive support to avoid hypotension. In these patients corticosteroid therapy may have potential therapeutic implications to treat hemodynamic instability.
    Journal of endocrinological investigation 06/2007; 30(5):393-8. · 1.65 Impact Factor
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    ABSTRACT: Posttraumatic carotid-cavernous fistula (PtCCF) is an uncommon complication after cranioencephalic trauma. It is usually diagnosed with a cerebral arteriography when the clinical symptoms have already appeared. The transcranial color-coded duplex sonography (TCDS) is a non-invasive technique at the patient's bedside that permits visualization of the circle of Willis and the intracavernous segment of the internal carotid artery. The initial sonographic patterns that suggest the presence of a PtCCF by TCDS are a mosaic image in color mode, presence of arterial and venous flows mixed with high velocity and low resistances. We present our experience in the early and non-invasive diagnosis of PtCFF in an Intensive Care Unit.
    Medicina Intensiva 01/2007; 31(1):46-9. · 1.32 Impact Factor
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    Intensive Care Medicine 01/2007; 32(12):2078; author reply 2079. · 5.26 Impact Factor
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    ABSTRACT: Transcranial sonography is a common tool for monitoring neurocritical patients. Transcranial color-coded duplex ultrasonography enables hemodynamic and structural study of the cerebral parenchyma in these patients. Its advantages over conventional ultrasonography are evident and are derived from direct visualization of the vessel to be studied and appropriate adjustment of the sample volume and angle of insonation. The use of ultrasonographic contrast agents enables conclusive findings in practically 100% of cases and allows cerebral perfusion to be studied at the bedside using semiquantitative methods. This review aims to show the applications of transcranial color-coded duplex ultrasonography for monitoring neurocritical patients in intensive care units.
    Medicina Intensiva 01/2007; 31(9):510-517. · 1.32 Impact Factor
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    ABSTRACT: Posttraumatic carotid-cavernous fistula (PtCCF) is an uncommon complication after cranioencephalic trauma. It is usually diagnosed with a cerebral arteriography when the clinical symptoms have already appeared. The transcranial color-coded duplex sonography (TCDS) is a non-invasive technique at the patient's bedside that permits visualization of the circle of Willis and the intracavernous segment of the internal carotid artery. The initial sonographic patterns that suggest the presence of a PtCCF by TCDS are a mosaic image in color mode, presence of arterial and venous flows mixed with high velocity and low resistances. We present our experience in the early and non-invasive diagnosis of PtCFF in an Intensive Care Unit.
    Medicina Intensiva 01/2007; 31(1):46-49. · 1.32 Impact Factor