Steroid treatment in ARDS: a critical appraisal of the ARDS network trial and the recent literature

OBJECTIVES

To compare the design and results of randomized trials investigating prolonged glucocorticoid treatment (> or =7 days) in patients with acute lung injury-acute respiratory distress syndrome (ALI-ARDS), and review factors affecting response to therapy, including the role of secondary prevention.

DESIGN

Trials were retrieved from the Cochrane Central Register of Controlled Trials (CENTRAL). Two investigators collected data on study characteristics, treatment intervention, and outcomes. The methodological quality of trials was determined and data were analyzed with Review Manager 4.2.3.

MEASUREMENTS AND RESULTS

Five selected trials (n=518) consistently reported significant improvement in gas exchange, reduction in markers of inflammation, and decreased duration of mechanical ventilation and intensive care unit stay (all p<0.05). Two early small clinical trials showed marked reductions in the relative risk (RR) of death with glucocorticoid therapy (RR=0.14, 95% CI 0.04-0.53; p=0.004, I2=0%). Three subsequent larger trials, when combined, although nominally beneficial, did not reproduce the marked reductions observed in the earlier trials (RR=0.84; 95% CI 0.68-1.03; p=0.09, I2=9.1%), but achieved a distinct reduction in the RR of death in the larger subgroup of patients (n=400) treated before day 14 of ARDS [82/214 (38%) vs. 98/186 (52.5%), RR=0.78; 95% CI 0.64-0.96; p=0.02, I2=0%].

CONCLUSIONS

Prolonged glucocorticoid treatment substantially and significantly improves meaningful patient-centered outcome variables, and has a distinct survival benefit when initiated before day 14 of ARDS.

[Recombinant factor VIIa (rFVIIa). Description of use in a cohort of critical patients and prognostic markers]

OBJECTIVE

Describe and identify the factors associated with the survival of the patients who received treatment with rFVIIa in an Intensive Care Unit (ICU).

DESIGN

Longitudinal, ambispective, observational, descriptive study in a series of clinical cases performed from July 20, 2004 to July 20, 2006.

SCOPE

The study population included 16 hospitalized patients in the Intensive Medicine Department (ICU) of the Hospital Marqués de Valdecilla (Santander).

PATIENTS

Inclusion criteria were: Patients who required rFVIIa at some time of their stay in the ICU.

RESULTS

Hemodynamic improvement of the patients treated with rFVIIa in an ICU, within the first 3 hours of the infusion (evaluated by an increase of SBP > 20 mmHg and/or increase of DBP > 8 mmHg) was associated to greater survival.

CONCLUSIONS

The present series of cases, with the disadvantage of its heterogeneity and the limited number of patients, stresses the role of hemodynamic improvement as a differentiating factor between those patients who survive and those who do not.

[GEIPC-SEIMC (Study Group for Infections in the Critically Ill Patient of the Spanish Society for Infectious Diseases and Clinical Microbiology) and GTEI-SEMICYUC ( Working Group on Infectious Diseases of the Spanish Society of Intensive Medicine, Critical Care, and Coronary Units) recommendations for antibiotic treatment of gram-positive cocci infections in the critical patient]

In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired-infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Crítico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

Quality of life before surgical ICU admission

BACKGROUND

Examining the quality of life (QOL) of patients before ICU admission will allow outcome variables to be compared and analyzed in relation to it. The objective of this study was to analyze QOL of patients before admission to a surgical ICU and to study its relationship to outcome and to the baseline characteristics of the patients.

METHODS

All adult patients consecutively admitted to the surgical ICU between November 2004 and April 2005, who underwent non-cardiac surgery, were enrolled in this observational and prospective study. The following patient characteristics were recorded: age, gender, body mass index, ASA physical status, type and magnitude of surgical procedure, length of stay (LOS), in ICU and in hospital, mortality, Simplified Acute Physiology Score II (SAPS), history of co-morbidities and quality of life survey score (QOLSS). The relationships between QOLSS and ICU variables and outcome were evaluated. The relationship between the total QOLSS and each variable or outcome was assessed by multiple linear regression.

RESULTS

One hundred eighty seven patients completed the study. The preadmission QOLSS of the patients studied was 4.43 +/- 4.90; 28% of patients had a normal quality of life (0 points), 38% had between 1 and 5 points (considered mild deterioration), 21% had between 6 and 10 points (moderate deterioration), 10% had between 11 and 15 points (considered major deterioration) and 3% had more than 15 points (severe limitation of quality of life). A worse preadmission QOLSS was associated with higher SAPS II scores, with older patients (age> 65 years) and with ASA physical status (ASA III/IV). Total QOLSS was significantly worse in elderly patients and in patients with co-morbidities and in patients more severely ill at ICU admission. Patients who died in the ICU and in hospital had worse QOLSS scores compared to those who survived. However, no statistical differences in QOLSS were found in relation to longer ICU stays (ICU LOS).

CONCLUSION

Preadmission QOL correlates with age and severity of illness. Patients with co-morbidities and those who died during ICU or hospital stay had worse QOLSS scores.

Severe head injury among children: computed tomography evaluation as a prognostic factor

BACKGROUND

The value of neuroimaging in predicting unfavorable events in the outcome of pediatric patients has not been established. Our objectives were to determine clinical characteristics and outcome of severely head-injured children admitted to the pediatric intensive care unit (PICU) of a pediatric third-level university hospital and to evaluate the use of neuroimaging as a prognostic factor of morbimortality in these patients.

METHODS

We performed a 9-year retrospective review. We included all patients with severe head injury admitted to the pediatric intensive care unit of our hospital from January 1995 to December 2003 requiring invasive intracranial pressure monitoring. Clinical summaries and imaging studies were reviewed.

RESULTS

Data for 156 pediatric patients, aged 1 to 18 years, were collected. We reclassified neuroimaging patterns into 2 groups: those with few imaging findings and those with important lesions. These 2 groups were significantly correlated with initial Glasgow Coma Scale (P < .05). We classified patients into favorable evolution, moderate disability, and unfavorable evolution. Poorer evolution correlated with poorer initial neuroimaging patterns, and these differences were statistically significant (P < .05).

CONCLUSIONS

In our group of patients, initial Glasgow Coma Scale was related with the initial neuroimaging pattern, and this relation was statistically significant. Findings in the first and second neuroimaging were useful as prognostic factors in our series.

[Safety and efficacy of the MARS therapy applied by continuous renal replacement therapy (CRRT) monitors]

OBJECTIVE

Analyze the utility and safety of MARS therapy applied with the CRRT monitor.

DESIGN

Prospective study of cohorts.

SCOPE

Polyvalent ICU in tertiary university hospital with hepatic transplantation program.

PATIENTS

Thirty one patients: 9 (22.6%) with acute liver failure (ALF) (1 hepatic surgery, 1 primary graft failure, 7 other causes) and 22 (71%) with acute-on-chronic failure (AoCLF).

INTERVENTIONS

For the treatment, the patients with ALF are maintained in the ICU but those with AoCLF are admitted for the performance of the different sessions, that are programmed for a duration of at least 15 hours in AoCLF and in ALF are maintained continuously, changing the circuit every 24 hours.

VARIABLES OF INTEREST

Metabolic control and complications registered in 75 sessions on 31 patients.

RESULTS

Urea decrease was 33.5 (29-38%), creatinine 36 (31-41%), total bilirubin 29 (25-33%) and direct bilirubin 34 (30-38%). Clearance was slower, but sustained, after the first 4 hours of each session both for urea (p<0.001) as well as for bilirubin (p<0.05). The hemodynamic parameters improved and the hematological ones were not altered. We detected decrease in platelets (131 to 120x109/L, p<0.01). In 95 of the sessions in which heparin was used and in 6% where epoprostenol was used, we observed mild bleeding. We cultured albumin of the circuit at the end of the session in 50 occasions and only obtained growth in 3 cases (6%) (2 Staphylococcus epidermidis, 1 S. haemolyticus) without signs of contamination in the patients.

CONCLUSIONS

The MARS system applied by CRRT monitors provide adequate bilirubin clearance percentages and is safe, even in serious patients. Prolongation of the duration of the sessions was not accompanied by an increase in the risk of infection secondary to the albumin contamination.

Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study

BACKGROUND

The aim of this study is to evaluate the association between acute serum creatinine changes in acute renal failure (ARF), before specialized treatment begins, and in-hospital mortality, recovery of renal function, and overall mortality at 6 months, on an equal degree of ARF severity, using the RIFLE criteria, and comorbid illnesses.

METHODS

Prospective cohort study of 1008 consecutive patients who had been diagnosed as having ARF, and had been admitted in an university-affiliated hospital over 10 years. Demographic, clinical information and outcomes were measured. After that, 646 patients who had presented enough increment in serum creatinine to qualify for the RIFLE criteria were included for subsequent analysis. The population was divided into two groups using the median serum creatinine change (101%) as the cut-off value. Multivariate non-conditional logistic and linear regression models were used.

RESULTS

A >or= 101% increment of creatinine respect to its baseline before nephrology consultation was associated with significant increase of in-hospital mortality (35.6% vs. 22.6%, p < 0.001), with an adjusted odds ratio of 1.81 (95% CI: 1.08-3.03). Patients who required continuous renal replacement therapy in the >or= 101% increment group presented a higher increase of in-hospital mortality (62.7% vs 46.4%, p = 0.048), with an adjusted odds ratio of 2.66 (95% CI: 1.00-7.21). Patients in the >or= 101% increment group had a higher mean serum creatinine level with respect to their baseline level (114.72% vs. 37.96%) at hospital discharge. This was an adjusted 48.92% (95% CI: 13.05-84.79) more serum creatinine than in the < 101% increment group.

CONCLUSION

In this cohort, patients who had presented an increment in serum level of creatinine of >or= 101% with respect to basal values, at the time of nephrology consultation, had increased mortality rates and were discharged from hospital with a more deteriorated renal function than those with similar Liano scoring and the same RIFLE classes, but with a < 101% increment. This finding may provide more information about the factors involved in the prognosis of ARF. Furthermore, the calculation of relative serum creatinine increase could be used as a practical tool to identify those patients at risk, and that would benefit from an intensive therapy.

Management of postintubation tracheobronchial rupture: our experience and a review of the literature

Iatrogenic tracheobronchial ruptures are rare but severe complications after intubation. Therefore, we evaluated the reasons, the therapy and the outcome of patients with postintubation tracheal rupture, who were admitted to our intensive care unit. We reviewed the literature of tracheal rupture after endotracheal intubation in respects of the risk factors, diagnosis, the possible mechanisms of the injury, and suggest strategies of management.

Risk factors for candidaemia in critically ill patients: a prospective surveillance study

Candidaemia is frequently a life-threatening complication in patients admitted to the intensive care unit (ICU). To assess the risk factors for candidaemia in critically ill patients with prolonged ICU stay, a total of 1765 adult patients admitted for at least 7 days to 73 medical-surgical ICUs of 70 tertiary care hospitals in Spain participated in a prospective cohort study. Candidaemia was defined as recovery of Candida spp. from blood culture. Sixty-eight episodes of candidaemia occurred in 63 patients, representing 35.7 episodes per 1000 ICU patients admitted, with an incidence rate of 1.5 episodes per 1000 days of ICU stay. Causative fungi were C. albicans in 57.1% of cases and non-albicans Candida spp. in 42.9%. In the multivariate analysis, independent factors significantly associated with candidaemia were Candida colonisation (OR = 4.12, 95% CI: 1.82-9.33), total parenteral nutrition (OR = 3.89, 95% CI: 1.73-8.78), elective surgery (OR = 2.75, 95% CI: 1.17-6.45) and haemofiltration procedures (OR = 1.96, 95% CI: 1.06-3.62). In the ICU setting in Spain and in patients who have stayed in units for >7 days, more than half of cases of candidaemia were caused by C. albicans. Risk factors for candidaemia identified included Candida colonisation, elective surgery, total parenteral nutrition and haemodialysis.

Evaluation of the Oxygenation Ratio as Long-Term Prognostic Marker After Lung Transplantation

OBJECTIVE

We hypothesized that the arterial blood gas oxygen tension/fraction of inspired oxygen ratio (PaO2/FiO2) would prove to be useful as a mortality marker after lung transplantation (LT). The aims of this study were to define the prevalence of various ranges of PaO2/FiO2 during the first 24 hours after LT and to evaluate which measurement using the PaO2/FiO2 best correlates with mortality.

METHODS

A retrospective study was performed that included all patients who underwent LT from 1997 to 2005. We collected PaO2/FiO2 ratios at 0, 12, and 24 hours after admission to the intensive care unit (ICU). We classified the 132 patients in 5 groups, based on PaO2/FiO2 (Group 1, PaO2/FiO2 <100; Group 2, PaO2/FiO2 100-199; Group 3, PaO2/FiO2 200-299; Group 4, PaO2/FiO2 300-399; Group 5, PaO2/FiO2 >or=400). The correlation between PaO2/FiO2 and mortality was studied using Cox regression.

RESULTS

Cox regression analysis showed that PaO2/FiO2 at 0 and 12 hours after admission to the ICU were not useful mortality markers. However, the PaO2/FiO2 at 24 hours after admission to the ICU was a useful long-term prognostic marker. PaO2/FiO2 >100 (groups 2, 3, 4, and 5) at 24 hours was significantly associated with less mortality when a lower PaO2/FiO2 was the reference (hazard Ratio: 0.08, 0.02, 0.05, and 0.02, respectively). On multivariate analysis PaO2/FiO2 >or=100 (groups 2, 3, 4, and 5) at 24 hours was significantly associated with less mortality when a lower PaO2/FiO2 was the reference (hazard ratio: 0.07, 0.003, 0.01, and 0.005, respectively).

CONCLUSIONS

A value of PaO2/FiO2 >100 mm Hg 24 hours after admission to the ICU is associated with a lower mortality.

Internal mammary artery injury after central venous catheterization

OBJECTIVE

We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization.

DESIGN

Report of cases.

SETTING

Pediatric intensive care unit.

PATIENTS

The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later.

INTERVENTIONS

None.

CONCLUSIONS

Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.

Prognosis Factors in Lung Transplant Recipients Readmitted to the Intensive Care Unit

OBJECTIVE

To identify outcome predictors and prognostic factors for survival among lung transplant recipients on readmission to the intensive care unit (ICU).

METHODS

This was a retrospective study of all lung transplant recipients during a 10-year period from 1997 to 2006. Data collection included age, gender, reason, and type of lung transplantation. Variables specific to individual ICU admissions included admission diagnosis, length of stay, duration of mechanical ventilation, interval from transplantation, Acute Physiology and Chronic Health Evaluation (APACHE) II score on ICU admission, and the identification of systemic organ dysfunction. We used Student t test (or where appropriate, its nonparametric equivalent) or the chi(2) test for comparisons among the patients who died and those who survived their ICU readmissions.

RESULTS

Among 144 lung transplant patients 28 were later readmitted to the ICU after at least 1 week. The admission diagnosis was sepsis in 20 cases (71.4%). Seventeen patients died during their ICU stay (60.7%). A higher APACHE II score (P = .008), the presence of three or more dysfunctional organs upon readmission (P = .016), and the need for mechanical ventilation (P = .022) were risk factors for mortality. The mortality risk was also higher among the group with a longer delay to ICU readmission (P = .003).

DISCUSSION

Readmission to the ICU, which is common among lung transplant recipients, was associated with a high mortality. Sepsis was the main cause of ICU readmission and the most frequent cause of death. APACHE II score, need for mechanical ventilation, number of dysfunctional organs, and delay in ICU readmission were important prognostic factors.

Recomendaciones GEIPC-SEIMC y GTEI-SEMICYUC para el tratamiento antibiótico de infecciones por cocos grampositivos en el paciente crítico

In recent years, an increment of infections caused by gram-positive cocci has been documented in nosocomial and hospital-acquired infections. In diverse countries, a rapid development of resistance to common antibiotics against gram-positive cocci has been observed. This situation is exceptional in Spain but our country might be affected in the near future. New antimicrobials active against these multi-drug resistant pathogens are nowadays available. It is essential to improve our current knowledge about pharmacokinetic properties of traditional and new antimicrobials to maximize its effectiveness and to minimize toxicity. These issues are even more important in critically ill patients because inadequate empirical therapy is associated with therapeutic failure and a poor outcome. Experts representing two scientific societies (Grupo de estudio de Infecciones en el Paciente Critico de la SEIMC and Grupo de trabajo de Enfermedades Infecciosas de la SEMICYUC) have elaborated a consensus document based on the current scientific evidence to summarize recommendations for the treatment of serious infections caused by gram-positive cocci in critically ill patients.

Improving outcome of human immunodeficiency virus-infected patients in a Mexican intensive care unit

BACKGROUND

In Latin America, insufficient data are available to improve local admission policies for human immunodeficiency virus (HIV) patients in the intensive care units (ICU). We undertook this study to evaluate the outcome and survival determinants of HIV patients in a Mexican ICU during three time periods.

METHODS

From December 1985 through January 2006, a clinical chart-based, retrospective study of all HIV patients admitted to the ICU was conducted. Demographic, clinical and laboratory data; disease severity score (APACHE II) and mortality were evaluated. A comprehensive database was created and data were analyzed using survival and regression models.

RESULTS

Ninety HIV patients were admitted to the ICU during the study: 16 (18%) in 1985-1992 (non-antiretroviral [ARV]-period), 21 (23%) in 1993-1996 (ARV-period), and 53 (58%) in 1996-2006 (highly active antiretroviral treatment [HAART] period). Leading reasons for admission were the need for mechanical ventilatory support (MVS, 85.5%), septic shock (23%), and non-HIV/AIDS complications (15.5%). Survival in the ICU increased from 12.5% (non-ARV period) to 57% (HAART period). Mortality during ICU stay was associated with MVS (HR: 3.2; 95% CI 1.0-10.2) and APACHE II > or =13 points (HR: 2.2; 95% CI 1.3-4.0). Use of steroids (HR: 0.4; 95% CI 0.2-0.8) and HAART (HR: 0.25; 95% CI 0.1-0.5) were associated with a lower risk of death. In multivariate analysis, septic shock was the main predictor of death in the ICU (HR: 2.4; 95% CI 1.1-5.2) and after discharge. HAART remained as a significant protective factor.

CONCLUSIONS

Overall survival in Mexican HIV patients admitted to an ICU has substantially increased in recent years. These data should encourage policies that consider HIV patients as good candidates for receiving intensive care.

Replacement of 24-h creatinine clearance by 2-h creatinine clearance in intensive care unit patients: a single-center study

OBJECTIVE

To estimate the usefulness of 2-h creatinine clearance (CrCl) in the ICU and define variables that may reduce agreement.

DESIGN

Prospective study.

SETTING

Polyvalent ICU of a university hospital.

PATIENTS

359 patients.

INTERVENTIONS

We compared 24-h CrCl (CrCl-24h), as the standard measure, with 2-h CrCl (CrCl-2h) (at the start of the period) and the Cockroft-Gault equation (Ck-G).

MEASUREMENTS AND RESULTS

The 2-h sample was lost in two patients (0.6%) and the 24-h sample was lost in 50 patients (13.9%). The mean Ck-G was 87.4+/-3.05, with CrCl-2h 109.2+/-4.46 and CrCl-24h 100.9+/-4.21 ml/min/1.73 m2 (r2 of 0.88 for CrCl-2h and 0.84 for Ck-G). The differences from ClCr-24h were 21.8+/-3.3 (p<0.001) for the Ck-G and 8.3+/-2.6 (p<0.05) for CrCl-2h (p<0.05). In the subgroup of patients with CrCl-24h<100 ml/min/1.73 m2, the CrCl-24h value was 52.9+/-2.71 vs. 51.6+/-2.14 for CrCl-2h (p=ns) and 57.6+/-2.56 (p<0.001) for the Ck-G. Patients with CrCl<100 ml/min only showed variability in hyperglycemia during the 24-h period.

CONCLUSIONS

In intensive care patients, 24-h CrCl results in a large proportion of non-valid determinations, even under conditions of close monitoring. Two-hour CrCl is an adequate substitute, even in patients who are unstable or who have irregular diuresis where a 24-h collection is impossible. The Cockroft-Gault equation seems less useful in this setting.

The kidney in the critically ill

Acute kidney injury (AKI) is a common and serious complication in the intensive care setting. It seldom occurs in isolation, but is mostly part of a multiple organ dysfunction syndrome. The pathogenesis is frequently multifactorial, with sepsis contributing to 50% of the cases.The development of AKI in critically-ill patients is "bad news": patients with AKI have a high morbidity and mortality. In addition, AKI, even in its mildest from, is not only a marker of illness severity but appears to be independently associated with mortality. Prevention of AKI is therefore a major goal to improve outcome of critically-ill patients. Treatment of established AKI is largely supportive. The optimal modality for renal replacement therapy in critically-ill patients still remains a matter of debate). The majority of survivors recover renal function.

Intracranial pressure and cerebral perfusion pressure as risk factors in children with traumatic brain injuries

OBJECT

The authors evaluated the initial intracranial pressure (ICP) and cerebral perfusion pressure (CPP) as prognostic factors in severe head injury in children and tried to determine the optimal CPP range.

METHODS

The authors performed a 9-year retrospective review of all patients with severe traumatic brain injuries (TBIs) who required invasive ICP monitoring and were admitted to the pediatric intensive care unit at their institution between January 1995 and December 2003. These patients had Glasgow Coma Scale scores lower than 8 and/or required ICP monitoring due to worsening neurological status or neuroimaging results suggestive of cerebral hypertension. Clinical summaries and imaging studies were reviewed. Data for 156 pediatric patients who ranged in age from 1 to 18 years were obtained. Half of these patients presented with normal initial ICPs (< 20 mm Hg), and a good outcome was achieved in 80% of these children. An unfavorable outcome was observed in more than 60% of patients with an initial CPP lower than 40 mm Hg. The proportion of patients with an unfavorable outcome decreased to 10% with initial CPPs higher than 60 mm Hg, but patients with initial CPPs higher than 70 mm Hg did not improve.

CONCLUSIONS

Initial ICP and CPP measurements were useful as prognostic factors in pediatric patients with severe TBIs: patients with initial CPPs between 40 and 70 mm Hg were found to have a better neurological prognosis than those with CPPs either higher or lower than that range.

[Pseudomonas aeruginosa: combined treatment vs. monotherapy]

Pseudomonas aeruginosa is a pathogen commonly encountered in clinical practice in critically ill patients. It is a serious cause of infection, associated with a high rate of morbidity and mortality. Inappropriate antimicrobial therapy and delay in starting effective antimicrobial therapy is associated with worse prognostic. This microorganism is clinically indistinguishable from others forms of gram-negative bacterial infection. The rate of multidrug-resistant P. aeruginosa has increased in the last years. For these reasons, patients with Pseudomonas infection might receive empirical antibiotics that are inactive against Pseudomonas, especially before antibiotic susceptibility results become available. It remains controversial whether combination therapy, given empirically or as definitive treatment, for suspected Pseudomonas aeruginosa infections is justifiable. In the present article, we aimed to review recent studies that have evaluated the impact of combination therapy on Pseudomonas infections outcome and we exhibit our point of view in this subject. It seems justifiable to start combination therapy with two antipseudomonal agents in patients with risk for Pseudomonas infection during the first 3-5 days, until having microbiological results. This combination therapy must be changed to monotherapy on the basis on the specific susceptibility pattern of the initial isolate. In cases without microbiological diagnosis and poor outcome, combination therapy will be maintained and other causes of infection will be studied. Multicentre prospective randomized trials in critically ill patients are needed to determine which antimicrobials combinations improve outcome in Pseudomonas infections.

[Limitation of therapeutic effort after ICU admission. Analysis of related factors]

OBJECTIVE

To analyze the limitation of therapeutic effort (LTE) in our Intensive Care Unit (ICU) and the variables associated with that decision.

DESIGN

Prospective cohort study with a follow up of one year after discharge.

SETTING

ICU of a second level hospital.

PATIENTS

Four hundred and nine patients admitted during a two-year period.

MAIN VARIABLES

APACHE II, NEMS, SOFA, quality of life (PAEEC) and mortality.

RESULTS

LTE was performed in 49 (12%) patients. This decision was made by general agreement among the care team in 88% of cases and with the family in 73.5%. It was made on day 8 (4-20) with a SOFA score of 9 (4-13). Mortality in the LTE group was 69.4% in ICU, 92% in hospital, and 96% at 6 and 12 months. A logistic regression model showed that the variables associated with LTE were the following: NEMS score >or=30.7 (OR 12; 95% CI 3.7-39, p < 0.001), NEMS 26.6-30.6 (OR 8; 95% CI 2.5-25.6, p = 0.001), APACHE II > 30 (OR 7.6; 95% CI 2-29, p = 0.003), quality of life >or= 7 (OR 4.2; 95% CI 1.1-15, p = 0.03), age >or= 80 (OR 3.7, 95% CI 1.4-9.5, p = 0.007) and medical patient condition (OR 3.5; 95% CI 1.5-8, p = 0.003).

CONCLUSIONS

LTE is a common practice and is usually performed among the care team and the patient's surrogates. The main variables associated with LSC are those related to the severity of illness, previous quality of life, medical disease and patient's age.

[Guidelines for the diagnosis and treatment of patients with bacteriemia. Guidelines of the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica]

Bacteremia is a complex clinical syndrome in constant transformation that is an important, growing cause of morbidity and mortality. Even though there is a great deal of specific information about bacteremia, few comprehensive reviews integrate this information with a practical AIM. The main objective of these Guidelines, which target hospital physicians, is to improve the clinical care provided to patients with bacteremia by integrating blood culture results with clinical data, and optimizing the use of diagnostic procedures and antimicrobial testing. The document is structured into sections that cover the epidemiology and etiology of bacteremia, stratified according to the various patient populations, and the diagnostic work-up, therapy, and follow-up of patients with bacteremia. Diagnostic and therapeutic decisions are presented as recommendations based on the grade of available scientific evidence.

Effect of population aging on the international organ donation rates and the effectiveness of the donation process

This study analyzed the effect of population aging on organ donation for transplants in 43 countries and on the effectiveness of the donation process by comparing the results between Spain and the United States. The percentage of the population aged 65 or over accounted for 33% of the difference in the donation rates between the countries and for 91% of the variation in the rates after age adjustment. However, the level of aging of the Spanish (16.5%) and American (12.3%) populations failed to account for the percentages of deceased donors 65 or over (28% vs. 10%), due to the different age-specific donation rates, much higher in Spain above 50 years. These differences lead to a higher effectiveness of the process in the United States (3.1 transplanted organs per donor vs. 2.5 in Spain), though at lower rates of transplant per million population (73 vs. 87). We conclude that older populations have a greater donation potential as donation rates are strongly associated with population aging. It should therefore be mandatory to adjust donation rates for age before making comparisons. Additionally, effectiveness decreases with older donors, so age should be considered when establishing standards relating to organ donation and effectiveness of the process.

Modelo predictivo de neumonía nosocomial en unidades de cuidados intensivos

BACKGROUND AND OBJECTIVE

Nosocomial pneumonia is the most common nosocomial infection in the intensive care units (ICUs) and contributes disproportionately to both poor outcomes and high cost of care in critically ill patients. In order to identify patients with greater risk of developing nosocomial pneumonia in ICUs, it is important to select the right preventive measures.

PATIENTS AND METHOD

It was an observational study of 2 prospective cohorts of patients staying in the ICU for 24 h or more: the main cohort (n=1,184) and the validation cohort (n=554). A predictive model was constructed with the data of the main cohort using a logistic regression. Receiver operating characteristic (ROC) curves and predictive values for different cut points were obtained with the data of both cohorts.

RESULTS

Eight variables were selected for the predictive model: parenteral nutrition, enteral nutrition, nasogastric intubation, tracheostomy, mechanical ventilation, previous surgery, coma and diabetes. In the main cohort, the model had a sensitivity of 81% and a specificity of 78.4% in predicting nosocomial pneumonia (Hosmer-Lemeshow statistic p=0.93; area under ROC curve=0.861; 95% confidence interval, 0.824-0.898). In the validation cohort, the area under ROC curve was 0.849 (95% confidence interval, 0.742-0.956).

CONCLUSIONS

The resulting model presents satisfactory results in both cohorts. In addition, the variables used are simple, routinely available, and familiar to clinicians.

Coste de oxígeno de la respiración y predicción del éxito de la desconexión de la ventilación mecánica

OBJECTIVE

To determine whether the oxygen cost of breathing (VO2 resp) may predict successful weaning from mechanical ventilation.

DESIGN

A prospective clinical study.

SETTING

A polyvalent intensive care unit of a teaching hospital.

PATIENTS

Thirty non-consecutive mechanically ventilated patients ready to wean. Successful weaning was considered when reintubation was not needed for 48 h after extubation.

INTERVENTIONS

Spontaneous breathing test with a t-tube. VO2 resp was measured with the Douglas bag method.

RESULTS

Successful weaning was present in 20 (67%) of 30 patients. No patient with successful weaning needed tracheal reintubation. A cut-off value for VO2 resp <or= 10% had the highest value for the ROC curve (0.96 +/- 0.03) and +LR (9.5; 95% CI: 1.5 - 61) and -LR (0.1; 95% CI: 0.01 - 0.4) to distinguish between success or failure of weaning. A misclassification error of 7% was present to predict successful weaning.

CONCLUSION

The oxygen cost of breathing has no clinical utility in predicting weaning outcome.

The societal costs of intracerebral hemorrhage in Spain

This study estimates the lifetime societal costs associated with incident intracerebral hemorrhage (ICH) in Spain. An epidemiological model of ICH incidence, survival and morbidity was developed using retrospective data from 28 hospitals in Andalusia and published data identified in a systematic literature review. Data on resource utilization and costs were obtained from five hospitals in the Canary Islands, whereas cost of outpatient care, informal care and lost productivity were obtained from standardized questionnaires completed by survivors of ICH. The lifetime societal costs of incident ICH in Spain is estimated at 46,193 euros per patient. Direct medical costs accounted for 32.7% of lifetime costs, whilst 67.3% were related to indirect costs. One-third of direct medical costs over the first year were attributable to follow-up care, including rehabilitation. Indirect costs were dominated by costs of informal care (71.2%). The aggregated lifetime societal costs for the estimated 12,534 Spanish patients with a first-ever ICH in 2004 was 579 million euros. ICH implies substantial costs to society primarily due to formal and informal follow-up care and support needed after hospital discharge. Interventions that offer survival benefits without improving patients' functional status are likely to further increase the societal costs of ICH.

[Inflammatory state in patients with atrial fibrillation before and after electrical cardioversion]

OBJECTIVE

To assess the inflammatory state in patients with persistent atrial fibrillation and to determine the predictive value in the success of cardioversion and recurrence at 30 days.

DESIGN

Prospective observational case-control study.

PATIENTS

We included consecutively 49 patients with atrial fibrillation previously to scheduled electrical cardioversion in Coronary Care Unit. Clinical and echocardiographic variables were registered and High-sensivity C-reactive protein, interleukin-1beta, interleukin-6 and Tumour Necrosis Factor-alpha were measured. At 30-days follow-up, rhythm and biomarkers were reassessed. As control groups, we recruited 27 healthy volunteers and 16 patients matched for age, gender and cardiovascular risk factors.

RESULTS

Median age was 66 +/- 10 years and 38% were women. All the markers were higher in patients than in both control groups (p < 0.05). FNT-alpha and Interleukin-6 levels were higher in non-cardiovertors but only an enlarged atria was related to unsuccessful cardioversion (p = 0.036). High-sensivity C-reactive protein values in the higher cuartile tended to be related to recurrence of persistent atrial fibrillation (p = 0.06).

CONCLUSIONS

There is an increased inflammatory state in patients with atrial fibrillation. FNT-alpha and Interleukin-6 levels were increased in non-cardiovertors, but no biomarker was associated with success of cardioversion or rhythm state at 30-days. However, higher levels of hs-CRP showed a trend to be related to recurrence of atrial fibrillation.

[Breaking bad news in medicine: strategies that turn necessity into a virtue]

Breaking bad news is one of physician's most difficult duties. In spite of this, communication skills are considered a minor professional ability. Bad news is defined as any news that drastically and negatively alters the patient's view of his/her future. Patients never forget where, when and what bad news they were told. The factors that make communicating bad new difficult may come from the sociocultural setting of the patient or the doctor. Randomized studies have shown that communication learning skills may cause a positive impact on the person giving and receiving the bad news. In order to facilitate this task, a practical and dynamic 6-step protocol, described by Baile and Buckman, that may be useful for this task, is described.

Mecanismos biofísicos, celulares y modulación de la lesión pulmonar inducida por la ventilación mecánica

Ventilator-induced lung injury (VILI) is associated to a high rate of mortality with an important social impact. Mechanical ventilation induces structural and ultrastructural alterations in all cell types of the lung and can derive in the transduction of intracellular signals, as well as in changes in the expression of genes, a process known as mechanotransduction. Some of the conditions involved, such as inflammation and/or coagulation, apoptosis/necrosis can lead to the propagation of the injury outside the lung, resulting in multiorganic failure. VILI can be modulated by means of diverse interventions as the use of protective ventilatory modes, therapeutic approaches based on vasoactive and antioxidative drugs, and more recently treatments based on the use of repairing substances of the surfactant like poloxamers among others. Knowledge of the mechanisms involved in VILI is definitive for a better approach to this condition.

How important is the measurement of extravascular lung water?

PURPOSE OF REVIEW

Accurate quantification of extravascular lung water is an important issue in the management of patients with pulmonary edema. The single transpulmonary thermal indicator method has been available since the late 1990s. Its simplicity and easy application make it clinically attractive.

RECENT FINDINGS

Several experimental studies have confirmed the accuracy of the single transpulmonary thermal indicator technique in comparisons with postmortem gravimetric method. Whereas changes in extravascular lung water of less than 100-200% are undetectable by other clinically applicable methods of lung injury assessment (chest radiograph and oxygenation), the single transpulmonary indicator has proven highly sensitive to small (10-20%) increases and is therefore useful to detect incipient pulmonary edema. In patients with sepsis or acute respiratory distress syndrome, extravascular lung water measurement offers information unobtainable by other means.

SUMMARY

Extravascular lung water can be considered a relevant parameter that contributes to rational management of fluid and vasoactive therapy of many critically ill patients and offers a fuller picture of their overall lung function.

Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos

OBJECTIVE

Compare the influence of two preservation liquids, Euro-Collins (EC) and Perfadex (P) in the pulmonary graft function in the initial phase of lung transplant in humans.

DESIGN

Retrospective study.

SCOPE

Lung transplant unit of the ICU of a university hospital.

PATIENTS

A total of 79 patients were subjected to a transplant of both lungs. The pulmonary grafts were preserved with EC in 23 cases and with P in 56 cases.

VARIABLES OF INTEREST

Pulmonary function was assessed on admission in the intensive care unit (ICU) with the PaO2/FiO2 ratio. Mortality, graft dysfunction stay in ICU and time of mechanical ventilation were also assessed at 30 days.

RESULTS

The PaO2/FiO2 ratio was significantly greater in the P group than in the EC both on admission (p<0.006) and at 12 hours (p=0.032) in the ICU. Graft dysfunction incidence was less in group P than in EC (p<0.045). There were no differences in regards to mortality at 30 days, stay in ICU and time of mechanical ventilation between both groups.

CONCLUSION

Preservation of the pulmonary graft with P as preservation liquid compared with EC is associated with better graft function in the initial phases of transplant of both lungs and with a decrease in the incidence of graft dysfunction.