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Ramírez II, Gutiérrez-Arias R, Damiani LF, Adasme RS, Arellano DH, Salinas FA, Roncalli A, Núñez-Silveira J, Santillán-Zuta M, Sepúlveda-Barisich P, Gordo-Vidal F, Blanch L. Specific Training Improves the Detection and Management of Patient-Ventilator Asynchrony. Respir Care 2024; 69:166-175. [PMID: 38267230 PMCID: PMC10898470 DOI: 10.4187/respcare.11329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Patient-ventilator asynchrony is common in patients undergoing mechanical ventilation. The proportion of health-care professionals capable of identifying and effectively managing different types of patient-ventilator asynchronies is limited. A few studies have developed specific training programs, but they mainly focused on improving patient-ventilator asynchrony detection without assessing the ability of health-care professionals to determine the possible causes. METHODS We conducted a 36-h training program focused on patient-ventilator asynchrony detection and management for health-care professionals from 20 hospitals in Latin America and Spain. The training program included 6 h of a live online lesson during which 120 patient-ventilator asynchrony cases were presented. After the 6-h training lesson, health-care professionals were required to complete a 1-h training session per day for the subsequent 30 d. A 30-question assessment tool was developed and used to assess health-care professionals before training, immediately after the 6-h training lecture, and after the 30 d of training (1-month follow-up). RESULTS One hundred sixteen health-care professionals participated in the study. The median (interquartile range) of the total number of correct answers in the pre-training, post-training, and 1-month follow-up were significantly different (12 [8.75-15], 18 [13.75-22], and 18.5 [14-23], respectively). The percentages of correct answers also differed significantly between the time assessments. Study participants significantly improved their performance between pre-training and post-training (P < .001). This performance was maintained after a 1-month follow-up (P = .95) for the questions related to the detection, determination of cause, and management of patient-ventilator asynchrony. CONCLUSIONS A specific 36-h training program significantly improved the ability of health-care professionals to detect patient-ventilator asynchrony, determine the possible causes of patient-ventilator asynchrony, and properly manage different types of patient-ventilator asynchrony.
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Affiliation(s)
- Iván I Ramírez
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile.
- Faculty of Health Sciences, Diego Portales University, Santiago, Chile
- Division of Critical Care Medicine, Hospital Clinico de la Universidad de Chile, Santiago, Chile
- INTRehab Research Group, Santiago, Chile
| | - Ruvistay Gutiérrez-Arias
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile
- INTRehab Research Group, Santiago, Chile
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - L Felipe Damiani
- Departamento de ciencias de la salud, carrera de Kinesiología (Kinesiology career), Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo S Adasme
- Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
- Division of Pediatric Critical Care Medicine at Hospital Clínico Red de Salud Christus-UC. Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel H Arellano
- Division of Critical Care Medicine, Hospital Clinico de la Universidad de Chile, Santiago, Chile
| | - Francisco A Salinas
- Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile
- INTRehab Research Group, Santiago, Chile
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Santiago, Chile
| | | | - Juan Núñez-Silveira
- Division of Critical Care Medicine, Hospital Italiano, Buenos Aires, Argentina
| | - Milton Santillán-Zuta
- Critical Care Department, Hospital Nacional Guillermo Almenara, Lima, Perú
- Faculty of Health Science at Universidad Nacional Toribio Rodríguez de Mendoza, Amazonas, Perú
| | | | - Federico Gordo-Vidal
- Intensive Care Department, Hospital Universitario del Henares, Coslada, Madrid, Spain
- Grupo de investigación en patología crítica, Facultad de Medicina, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigacio i Innovacio Parc Taulí I3PT-CERCA, Universitat Autonoma de Barcelona, Sabadell, Spain
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de Haro C, Neto AS, Gomà G, González ME, Ortega A, Forteza C, Frutos-Vivar F, García R, Simonis FD, Gordo-Vidal F, Suarez D, Schultz MJ, Artigas A. Effect of a low versus intermediate tidal volume strategy on pulmonary complications in patients at risk of acute respiratory distress syndrome-a randomized clinical trial. Front Med (Lausanne) 2023; 10:1172434. [PMID: 37351068 PMCID: PMC10282840 DOI: 10.3389/fmed.2023.1172434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/02/2023] [Indexed: 06/24/2023] Open
Abstract
Introduction There is no consensus on whether invasive ventilation should use low tidal volumes (VT) to prevent lung complications in patients at risk of acute respiratory distress syndrome (ARDS). The purpose of this study is to determine if a low VT strategy is more effective than an intermediate VT strategy in preventing pulmonary complications. Methods A randomized clinical trial was conducted in invasively ventilated patients with a lung injury prediction score (LIPS) of >4 performed in the intensive care units of 10 hospitals in Spain and one in the United States of America (USA) from 3 November 2014 to 30 August 2016. Patients were randomized to invasive ventilation using low VT (≤ 6 mL/kg predicted body weight, PBW) (N = 50) or intermediate VT (> 8 mL/kg PBW) (N = 48). The primary endpoint was the development of ARDS during the first 7 days after the initiation of invasive ventilation. Secondary endpoints included the development of pneumonia and severe atelectases; the length of intensive care unit (ICU) and hospital stay; and ICU, hospital, 28- and 90-day mortality. Results In total, 98 patients [67.3% male], with a median age of 65.5 years [interquartile range 55-73], were enrolled until the study was prematurely stopped because of slow recruitment and loss of equipoise caused by recent study reports. On day 7, five (11.9%) patients in the low VT group and four (9.1%) patients in the intermediate VT group had developed ARDS (risk ratio, 1.16 [95% CI, 0.62-2.17]; p = 0.735). The incidence of pneumonia and severe atelectasis was also not different between the two groups. The use of a low VT strategy did neither affect the length of ICU and hospital stay nor mortality rates. Conclusions In patients at risk for ARDS, a low VT strategy did not result in a lower incidence of ARDS than an intermediate VT strategy.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02070666.
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Affiliation(s)
- Candelaria de Haro
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
| | - Gemma Gomà
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | - Alfonso Ortega
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Catalina Forteza
- Intensive Care Unit, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | - Raquel García
- Reanimation Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fabienne D. Simonis
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
| | - Federico Gordo-Vidal
- Intensive Care Unit, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - David Suarez
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
- Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Antonio Artigas
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Ramírez II, Gutiérrez-Arias R, Adasme RS, Arellano DH, Felipe Damiani L, Gordo-Vidal F. Effect of a specific training program on patient-ventilator asynchrony detection and management. Med Intensiva 2023; 47:353-355. [PMID: 36470737 DOI: 10.1016/j.medine.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/07/2022] [Accepted: 10/19/2022] [Indexed: 05/29/2023]
Affiliation(s)
- I I Ramírez
- Escuela de Kinesiología, Universidad Diego Portales, Manuel Rodríguez Sur 415, Santiago, Chile; Servicio de Medicina física y rehabilitación, Unidad de Kinesiología, Instituto Nacional del Tórax, Santiago, Chile.
| | - R Gutiérrez-Arias
- Servicio de Medicina física y rehabilitación, Unidad de Kinesiología, Instituto Nacional del Tórax, Santiago, Chile; Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago de Chile 7591538, Chile
| | - R S Adasme
- Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago de Chile 7591538, Chile; Division of Critical Care Medicine, Hospital Clínico Red de Salud Christus-UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - D H Arellano
- Division of Critical Care Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - L Felipe Damiani
- Departamento de Ciencias de la salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Gordo-Vidal
- Intensive Care Department, Hospital Universitario del Henares, Coslada, Madrid, Spain
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Cantón-Bulnes ML, Jiménez-Sánchez M, Alcántara-Carmona S, Gimeno-Costa R, Berezo-García JÁ, Beato C, Álvarez-Lerma F, Mojal S, Olaechea P, Gordo-Vidal F, Garnacho-Montero J. Determinants of mortality in cancer patients with unscheduled admission to the Intensive Care Unit: A prospective multicenter study. Med Intensiva 2022; 46:669-679. [PMID: 36442913 DOI: 10.1016/j.medine.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/07/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To analyze clinical features associated to mortality in oncological patients with unplanned admission to the Intensive Care Unit (ICU), and to determine whether such risk factors differ between patients with solid tumors and those with hematological malignancies. DESIGN An observational study was carried out. SETTING A total of 123 Intensive Care Units across Spain. PATIENTS All cancer patients with unscheduled admission due to acute illness related to the background oncological disease. INTERVENTIONS None. MAIN VARIABLES Demographic parameters, severity scores and clinical condition were assessed, and mortality was analyzed. Multivariate binary logistic regression analysis was performed. RESULTS A total of 482 patients were included: solid cancer (n=311) and hematological malignancy (n=171). Multivariate regression analysis showed the factors independently associated to ICU mortality to be the APACHE II score (OR 1.102; 95% CI 1.064-1.143), medical admission (OR 3.587; 95% CI 1.327-9.701), lung cancer (OR 2.98; 95% CI 1.48-5.99) and mechanical ventilation after the first 24h of ICU stay (OR 2.27; 95% CI 1.09-4.73), whereas no need for mechanical ventilation was identified as a protective factor (OR 0.15; 95% CI 0.09-0.28). In solid cancer patients, the APACHE II score, medical admission, antibiotics in the previous 48h and lung cancer were identified as independent mortality indicators, while no need for mechanical ventilation was identified as a protective factor. In the multivariate analysis, the APACHE II score and mechanical ventilation after 24h of ICU stay were independently associated to mortality in hematological cancer patients, while no need for mechanical ventilation was identified as a protective factor. Neutropenia was not identified as an independent mortality predictor in either the total cohort or in the two subgroups. CONCLUSIONS The risk factors associated to mortality did not differ significantly between patients with solid cancers and those with hematological malignancies. Delayed intubation in patients requiring mechanical ventilation might be associated to ICU mortality.
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Affiliation(s)
- M L Cantón-Bulnes
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain.
| | - M Jiménez-Sánchez
- Intensive Care Clinical Unit, Hospital Universitario Virgen de Rocío, Seville, Spain
| | | | - R Gimeno-Costa
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Á Berezo-García
- Intensive Care Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Beato
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Seville, Spain
| | - F Álvarez-Lerma
- Intensive Care Unit, Hospital del Mar - Parc de Salut Mar, Barcelona, Spain
| | - S Mojal
- Bioestadístico, Barcelona, Spain
| | - P Olaechea
- Hospital Universitario Galdakao-Usansolo, Biocruces Bizkaia Health Research Institute, Galdácano, Vizcaya, Spain
| | - F Gordo-Vidal
- Intensive Care Unit, Hospital Universitario del Henares, Coslada, Madrid, Spain; Grupo de Investigación en Patología Crítica, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - J Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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Pérez-Nieto OR, Mancilla-Galindo J, Mendiola-Villalobos C, Carrión-Moya JD, Zamarrón-López EI, Guerrero-Gutiérrez MA, Deloya-Tomás E, Sánchez-Díaz JS, Escarraman-Martinez D, Vásquez-Cuéllar AI, Kammar-García A, Soriano-Orozco R, Castañón-González JA, Gordo-Vidal F. Aplicaciones clínicas de la ecuación del movimiento del sistema respiratorio para la toma de decisiones en el paciente bajo ventilación mecánica invasiva: artículo de reflexión. Iatreia 2022. [DOI: 10.17533/udea.iatreia.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introducción: la ventilación mecánica es una práctica común en las unidades de cuidados intensivos y anestesiología. Tiene implicaciones terapéuticas, pero también es potencialmente nociva para el sistema respiratorio y los órganos distantes, por lo cual es imprescindible monitorizar los parámetros ventilatorios de manera continua.
Objetivo: describir la ecuación del movimiento del sistema respiratorio y sus aplicaciones clínicas en el paciente bajo ventilación mecánica.
Desarrollo: la ecuación del movimiento del sistema respiratorio integra las fuerzas dinámicas generadas por el ventilador y las propiedades intrínsecas del pulmón y la caja torácica. Expresa la presión en el sistema respiratorio en relación con el volumen, la elastancia, la resistencia, el flujo de aire y las presiones generadas por el ventilador y el paciente. Las presiones elevadas en el sistema respiratorio se asocian a una mayor mortalidad en pacientes con ventilación mecánica, por lo que la identificación de los componentes que condicionan la elevación de las presiones mediante la ecuación del movimiento del sistema respiratorio permite realizar modificaciones a los parámetros programados del ventilador para mantener una ventilación protectora.
Conclusión: la toma de decisiones basada en la ecuación del movimiento del sistema respiratorio permite realizar ajustes en los parámetros ventilatorios según las características y enfermedades del paciente bajo ventilación mecánica.
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Modesto I Alapont V, Medina Villanueva A, Del Villar Guerra P, Camilo C, Fernández-Ureña S, Gordo-Vidal F, Khemani R. OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO 2/FiO 2) and mechanical power. Systematic review and meta-analysis with meta-regression. Med Intensiva 2021; 45:516-531. [PMID: 34839883 DOI: 10.1016/j.medine.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/26/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING Not applicable. PATIENTS Fourteen RCTs were included in the study. INTERVENTIONS Not applicable. MAIN VARIABLES OF INTEREST Not applicable. RESULTS Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.
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Affiliation(s)
| | | | - P Del Villar Guerra
- Department of Pediatrics, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Camilo
- PICU, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - S Fernández-Ureña
- Urgencias Pediátricas, Complejo Hospitalario Universitario Materno Insular Las Palmas, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - F Gordo-Vidal
- ICU, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - R Khemani
- PICU, Children's Hospital Los Angeles, California, USA
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7
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Modesto I Alapont V, Medina Villanueva A, Del Villar Guerra P, Camilo C, Fernández-Ureña S, Gordo-Vidal F, Khemani R. OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO 2/FiO 2) and mechanical power. Systematic review and meta-analysis with meta-regression. Med Intensiva 2021; 45:S0210-5691(21)00075-9. [PMID: 34103170 DOI: 10.1016/j.medin.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/26/2021] [Accepted: 03/26/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING Not applicable. PATIENTS Fourteen RCTs were included in the study. INTERVENTIONS Not applicable. MAIN VARIABLES OF INTEREST Not applicable. RESULTS Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.
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Affiliation(s)
| | | | - P Del Villar Guerra
- Department of Pediatrics, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Camilo
- PICU, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - S Fernández-Ureña
- Urgencias Pediátricas, Complejo Hospitalario Universitario Materno Insular Las Palmas, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - F Gordo-Vidal
- ICU, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - R Khemani
- PICU, Children's Hospital Los Angeles, California, USA
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García-Garmendia JL, Gordo-Vidal F, Leal-Noval SR, Amaya-Villar R, Raimondi N, Ochagavía-Calvo A, Garnacho-Montero J. Fate of rejected manuscripts in the journal Medicina Intensiva during 2015-2017 period. Med Intensiva 2021; 45:271-279. [PMID: 34059217 DOI: 10.1016/j.medine.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To know the fate of the rejected manuscripts in Medicina Intensiva journal (MI) from 2015 to 2017 with surveillance until 2019. DESIGN Retrospective observational study. SETTING Biomedical journals publication. PARTICIPANTS Rejected manuscripts in MI journal. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Time of publication, impact factor (IF), generated citations and variables associated to publication. RESULTS The 69% (420) of analyzed articles (344 originals and 263 scientific letters) were rejected, and 205 (48.8%) were subsequently published, with 180 citations of 66 articles. Journal IF was lower in 173 (84.4%) articles. The number of FI-valid citations was higher than the FI of MI in 21 articles. Origin of manuscript OR 2,11 (IC 95% 1.29-3.46), female author OR 1.58 (IC 95% 1.03-2.44), english language OR 2,38 (IC 95% 1.41-4.0) and reviewed papers OR 1.71 (IC 95% 1.10-2.66) were associated to publication in PubMed database. CONCLUSIONS The rejected articles in MI have a mean publication rate in other journals. Most of these articles are published in journals with less IF and fewer citations than the IF of MI.
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Affiliation(s)
| | - F Gordo-Vidal
- Hospital Universitario del Henares, Grupo de investigación en Patología Crítica, Universidad Francisco de Vitoria, Madrid, Spain
| | | | | | - N Raimondi
- Hospital Municipal Juan A. Fernández, Buenos Aires, Argentina
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Manrique-Rodríguez S, Heras-Hidalgo I, Pernia-López MS, Herranz-Alonso A, Del Río Pisabarro MC, Suárez-Mier MB, Cubero-Pérez MA, Viera-Rodríguez V, Cortés-Rey N, Lafuente-Cabrero E, Martínez-Ortega MC, Bermejo-López E, Díez-Sáenz C, López-Sánchez P, Gaspar-Carreño ML, Achau-Muñoz R, Márquez-Peiró JF, Valera-Rubio M, Domingo-Chiva E, Aquerreta-González I, Ariño IP, Martín-Delgado MC, Herrera-Gutiérrez M, Gordo-Vidal F, Rascado-Sedes P, García-Prieto E, Fernández-Sánchez LJ, Fox-Carpentieri S, Lamela-Piteira C, Guerra-Sánchez L, Jiménez-Aguado M, Sanjurjo-Sáez M. Standardization and Chemical Characterization of Intravenous Therapy in Adult Patients: A Step Further in Medication Safety. Drugs R D 2021; 21:39-64. [PMID: 33346878 PMCID: PMC7937591 DOI: 10.1007/s40268-020-00329-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intravenous drug administration is associated with potential complications, such as phlebitis. The physiochemical characteristics of the infusate play a very important role in some of these problems. AIM The aim of this study was to standardize the dilutions of intravenous drugs most commonly used in hospitalized adult patients and to characterize their pH, osmolarity and cytotoxic nature to better guide the selection of the most appropriate vascular access. METHODS The project was conducted in three phases: (i) standardization of intravenous therapy, which was conducted using a modified double-round Delphi method; (ii) characterization of the dilutions agreed on in the previous phase by means of determining the osmolarity and pH of each of the agreed concentrations, and recording the vesicant nature based on the information in literature; and (iii) algorithm proposal for selecting the most appropriate vascular access, taking into account the information gathered in the previous phases. RESULTS In total, 112 drugs were standardized and 307 different admixtures were assessed for pH, osmolarity and vesicant nature. Of these, 123 admixtures (40%), had osmolarity values >600 mOsm/L, pH < 4 or > 9, or were classified as vesicants. In these cases, selection of the most suitable route of infusion and vascular access device is crucial to minimize the risk of phlebitis-type complications. CONCLUSIONS Increasing safety of intravenous therapy should be a priority in the healthcare settings. Knowing the characteristics of drugs to assess the risk involved in their administration related to their physicochemical nature may be useful to guide decision making regarding the most appropriate vascular access and devices.
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Affiliation(s)
- Silvia Manrique-Rodríguez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain.
| | - Irene Heras-Hidalgo
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - M Sagrario Pernia-López
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
| | - Ana Herranz-Alonso
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
| | - M Camino Del Río Pisabarro
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Hospital Universitario Donostia, San Sebastián, Spain
| | - M Belén Suárez-Mier
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - M Antonia Cubero-Pérez
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Verónica Viera-Rodríguez
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Noemí Cortés-Rey
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - Elizabeth Lafuente-Cabrero
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Nursing Department, Hospital del Mar, Barcelona, Spain
| | - M Carmen Martínez-Ortega
- Sociedad Española de Infusión y Acceso Vascular (SEINAV), Madrid, Spain
- Preventive Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Esther Bermejo-López
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Díez-Sáenz
- Nursing Department (Intensive Care), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Piedad López-Sánchez
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital General de Tomelloso, Ciudad Real, Spain
| | - M Luisa Gaspar-Carreño
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital Intermutual de Levante, Valencia, Spain
| | - Rubén Achau-Muñoz
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital Intermutual de Levante, Valencia, Spain
| | - Juan F Márquez-Peiró
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital Perpetuo Socorro, Alicante, Spain
| | - Marta Valera-Rubio
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Esther Domingo-Chiva
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Irene Aquerreta-González
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Ignacio Pellín Ariño
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital de Torrejón de Ardoz, Madrid, Spain
| | - M Cruz Martín-Delgado
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital de Torrejón de Ardoz, Madrid, Spain
| | - Manuel Herrera-Gutiérrez
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Federico Gordo-Vidal
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital Universitario del Henares, Madrid, Spain
| | - Pedro Rascado-Sedes
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Complejo Hospitalario Universitario de Santiago de Compostela, La Coruña, Spain
| | - Emilio García-Prieto
- Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC), Madrid, Spain
- Intensive Care Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Sara Fox-Carpentieri
- Nursing Department, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Carlos Lamela-Piteira
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
- Pharmacy Department, Hospital Álvarez-Buylla, Mieres, Spain
| | - Luis Guerra-Sánchez
- Nursing Department (Coronary Unit), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Jiménez-Aguado
- Nursing Department (Coronary Unit), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Sanjurjo-Sáez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Sociedad Española de Farmacia Hospitalaria (SEFH), Madrid, Spain
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Fajardo A, Medina A, Modesto V, Gordo-Vidal F. El lado oculto de la hipoxemia. Rev chil anest 2020. [DOI: 10.25237/revchilanestv49n06-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Un síndrome de distrés respiratorio agudo (SDRA) se caracteriza por un incremento del intrapulmonar (medido por el cociente PaO2/FiO2) causado por una afectación alveolo-intersticial bilateral no explicada por sobrecarga hídrica. Sin embargo, hay casos de SDRA que presentan una marcada hipoxemia sin claros infiltrados pulmonares. Un ejemplo de este caso, que ha generado gran controversia, es la infección por SARS-CoV-2. El entendimiento de la fisiopato- logía de la hipoxemia es absolutamente clave para establecer la estrategia terapéutica más adecuada en cada paciente. Ante una hipoxemia grave (PaO2/FiO2 < 200 que representa un superior al 30%) y con una radiografía de tórax (o con TAC) sin claros y extensos infiltrados bilaterales, el podría deberse a una afectación vascular. Esto podría explicarse por dos causas: un aumento de las resistencias vasculares pulmonares (RVP), que genera un derecha- izquierda a través del foramen oval permeable (FOP) o una alteración del reflejo de vasoconstricción pulmonar hipóxico (VPH). El reflejo de VPH se activa en un intento por redistribuir el flujo vascular hacia las zonas mejor ventiladas. Sin embargo, existen situaciones (como infecciones víricas) que pueden alterar dicho reflejo y agravar la hipoxemia. Se ha propuesto el uso concomitante de fármacos vasoactivos (como el óxido nítrico inhalado) y vasopresores (como do- pamina o noradrenalina) con el objetivo de disminuir las RVP y el flujo a través del FOP; o para redistribuir el flujo a zonas mejor ventiladas si se sospecha una alteración del RVP.
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Ferri C, Marin-Corral J, Magret M, Bodí M, Trefler S, Díaz E, Martín-Loeches I, Yébenes JC, Cilloniz C, Masclans J, Gordo-Vidal F, Cordero L, Rodríguez A. Impact of non-invasive mechanical ventilation (niv) in critical patients with influenza (H1N1) PDM09. Intensive Care Med Exp 2015. [PMCID: PMC4797387 DOI: 10.1186/2197-425x-3-s1-a702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Garnero A, Abbona H, Gordo-Vidal F, Hermosa-Gelbard C. Modos controlados por presión versus volumen en la ventilación mecánica invasiva. Med Intensiva 2013; 37:292-8. [DOI: 10.1016/j.medin.2012.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/01/2012] [Accepted: 10/05/2012] [Indexed: 01/03/2023]
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García-Ureña MÁ, López-Monclús J, Melero-Montes D, Blázquez-Hernando LA, Castellón-Pavón C, Calvo-DurÁN E, Gordo-Vidal F, Aguilera-Del Hoyo LF. Video-assisted Laparoscopic Débridement for Retroperitoneal Pancreatic Collections: A Reliable Step-up Approach. Am Surg 2013. [DOI: 10.1177/000313481307900434] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.
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García-Ureña MÁ, López-Monclús J, Melero-Montes D, Blázquez-Hernando LA, Castellón-Pavón C, Calvo-Durán E, Gordo-Vidal F, Aguilera-del Hoyo LF. Video-assisted laparoscopic débridement for retroperitoneal pancreatic collections: a reliable step-up approach. Am Surg 2013; 79:429-433. [PMID: 23574855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.
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Gordo-Vidal F, Enciso-Calderón V. Síndrome de distrés respiratorio agudo, ventilación mecánica y función ventricular derecha. Med Intensiva 2012; 36:138-42. [DOI: 10.1016/j.medin.2011.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 08/31/2011] [Indexed: 12/17/2022]
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Martín Delgado MC, Gordo-Vidal F. [The quality and safety of intensive care medicine in Spain. More than just words]. Med Intensiva 2011; 35:201-5. [PMID: 21414688 DOI: 10.1016/j.medin.2011.02.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
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Mozo-Martín T, Gordo-Vidal F. [Strategies against refractory hypoxemia in the cases of severe H1N1 influenza]. Med Intensiva 2010; 34:431. [PMID: 20537427 DOI: 10.1016/j.medin.2010.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 03/22/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
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Gordo-Vidal F, Calvo-Herranz E, Abella-Álvarez A, Salinas-Gabiña I. Toxicidad pulmonar por hiperoxia. Med Intensiva 2010; 34:134-8. [DOI: 10.1016/j.medin.2009.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 04/20/2009] [Indexed: 10/20/2022]
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Gordo-Vidal F, Gómez-Tello V, Palencia-Herrejón E, Latour-Pérez J, Sánchez-Artola B, Díaz-Alersi R. [High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis]. Med Intensiva 2008; 31:491-501. [PMID: 18039449 DOI: 10.1016/s0210-5691(07)74856-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS). SOURCE OF DATA Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references. SELECTION OF STUDIES Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series. DATA EXTRACTION By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study. RESULTS Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p=0.001) CONCLUSIONS The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient.
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Affiliation(s)
- F Gordo-Vidal
- Unidad de Cuidados Intensivos, Fundación Hospital Alcorcón, Madrid, España.
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Gordo-Vidal F, Calvo Herranz E. Falsa imagen de neumotórax en radiografía simple. Med Intensiva 2008; 32:201. [DOI: 10.1016/s0210-5691(08)70941-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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