Gac Med Mex
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Double or triple combination therapy in systemic arterial hypertension: to whom, when and with what?
Systemic arterial hypertension (SAH) is the main risk factor for premature death in the world and in Mexico. Around 15.2 million Mexicans have been estimated to be diagnosed with SAH, out of which 7.48 million are affiliated to IMSS (evaluation of the financial risks considered in the Institutional Risk Management Program, ENSANUT, 2018). SAH is a complex, chronic disease that requires continuous medical attention with multifactorial risk reduction strategies, which go beyond numerical control in mm Hg of blood pressure and have been shown to be effective in reducing the vascular, cardiac and renal complications of the disease, as well as its impact on premature death. Continuous education and support in SAH self-management are essential to overcome the main challenges: treatment adherence and self-monitoring by the patient for the rest of his/her life.
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By April 2, 2020, only 116 days after the description of the first case of SARS-CoV2 virus infection, which causes the COVID-19 disease, 1,014,673 cases and 50,030 deaths have been recorded in 181 countries.1 In the United States, there have been 244,678 cases and 5,911 deaths recorded (in New York State alone, there are 93,053 cases and 2,538 deaths), while in Mexico, 1,378 cases and 37 deaths have been recorded. This number is expected to keep on increasing in both countries. The health system in Mexico, as well as in the rest of the world, will face an enormous problem in the months to come.
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Simultaneous mechanical ventilation of several patients with a single ventilator might reduce the deficit of these devices for the care of patients with acute respiratory failure due to Covid-19. ⋯ Simultaneous mechanical ventilation should be implemented by medical personnel with experience in the procedure, be restricted to two patients and carried out in the intensive care unit.
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Except for pregnant women, the management of critically ill patients with COVID-19 during the pandemic includes the standard procedures that are used for any patient that requires to be attended to at the intensive care unit, as well as limited administration of crystalloid solutions, orotracheal intubation, invasive mechanical ventilation in the event of patient clinical deterioration, and muscle relaxants continuous infusion only if necessary. Non-invasive mechanical ventilation and high-flow oxygen therapy are not recommended due to the generation of aerosol (associated with risk of viral spread among health personnel), and neither is extracorporeal membrane oxygenation or the use of steroids. So far, there is no specific antiviral treatment for patients with COVID-19, and neither are there results of controlled trials supporting the use of any.
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COVID-19 is characterized by acute respiratory distress syndrome progression, which ranges from mild to severe. A percentage of critically ill patients will require endotracheal intubation and mechanical ventilation; therefore, Mexican engineers from different places have had the initiative of creating mechanical ventilators. ⋯ Intubation per se induces lung damage, increases the risk of superinfection, and the number of days of ICU stay. Furthermore, non-selective use of artificial ventilators decreases the opportunity for patients who require a ventilator to survive and increases institutional care costs of both human and material resources.