Recommendations for antibiotic selection for severe nosocomial infections

Severe infection and its evolution to sepsis are becoming more prevalent every day and are among the leading causes of critical illness and mortality. Proper management is crucial to improve prognosis. This document addresses three essential points that have a significant impact on this objective: a) early recognition of patients with sepsis criteria, b) identification of those patients who suffer from an infection and have a high risk of progressing to sepsis, and c) adequate selection and optimization of the initial antimicrobial treatment.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Background

The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported.

Objective

This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients.

Methods

Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients.

Results

A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO₂ with non-rebreather mask, 90 (IQR 83–93) vs 91 (IQR 87–94); p < 0.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5–9) vs 4 (IQR 3–7); p < 0.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs 89%; p = 0.009), acute kidney injury (AKI) (58% vs 24%; p < 10⁻¹⁶), shock (42% vs 14%; p < 10⁻¹³), and arrhythmias (24% vs 11%; p < 10⁻⁴). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs 25%; p = 0.03, 33% vs 23%; p = 0.01 and 15% vs 3%, p = 10⁻⁷), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1–10, p = 0.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), p = 0.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), p < 10⁻⁴)], cardiac arrest [OR: 11.099 (3.389, 36.353), p = 0.0001], and septic shock [OR: 3.224 (1.486, 6.994), p = 0.002] had an increased risk-of-death.

Conclusions

Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades II or III and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Antecedentes

No se ha reportado plenamente la evolución clínica de los pacientes críticos de COVID-19 durante su ingreso en la unidad de cuidados intensivos (UCI), incluyendo las complicaciones médicas e infecciosas y terapias de soporte, así como su asociación con la mortalidad en UCI.

Objetivo

El objetivo de este estudio es describir las características clínicas y la evolución de los pacientes ingresados en UCI por COVID-19 y determinar los factores de riesgo de la mortalidad en UCI de dichos pacientes.

Métodos

Estudio prospectivo, multicéntrico y de cohorte, que incluyó a los pacientes críticos de COVID-19 ingresados en 30 UCI de España y Andorra. Se incluyó a los pacientes consecutivos del 12 de marzo al 26 de mayo del 2020 si habían fallecido o habían recibido el alta de la UCI durante el periodo de estudio. Se reportaron los datos demográficos, los síntomas, los signos vitales, los marcadores de laboratorio, las terapias de soporte, terapias farmacológicas y las complicaciones médicas e infecciosas, realizándose una comparación entre los pacientes fallecidos y los pacientes dados de alta.

Resultados

Se incluyó a un total de 663 pacientes. La mortalidad general en UCI fue del 31% (203 pacientes). Al ingreso en UCI los no supervivientes eran más hipoxémicos (SpO₂ con mascarilla de no reinhalación, de 90 [RIC 83-93] vs. 91 [RIC 87-94]; p < 0,001] y con mayor puntuación en la escala SOFA-Evaluación de daño orgánico secuencial (SOFA, 7 [RIC 5-9] vs. 4 [RIC 3-7]; p <0,001]). Las complicaciones fueron más frecuentes en los no supervivientes: síndrome de distrés respiratorio agudo (SDRA) (95% vs. 89%; p = 0,009), insuficiencia renal aguda (IRA) (58% vs. 24%; p < 10^–6), shock (42% vs. 14%; p < 10^–13) y arritmias (24% vs. 11%; p < 10^–4). Las superinfecciones respiratorias, infecciones del torrente sanguíneo y los shock sépticos fueron más frecuentes en los no supervivientes (33% vs. 25%; p = 0,03, 33% vs. 23%; p = 0,01 y 15% vs. 3%, p = 10^–7, respectivamente). El modelo de regresión multivariable reflejó que la edad estaba asociada a la mortalidad y que cada año incrementaba el riesgo de muerte en un 1% (IC del 95%: 1-10, p = 0,014). Cada incremento de 5 puntos en la escala APACHE II predijo de manera independiente la mortalidad (odds ratio [OR]: 1,508 [1,081, 2,104], p = 0,015). Los pacientes con IRA (OR: 2,468 [1,628, 3,741], p < 10^–4)], paro cardiaco (OR: 11,099 [3,389, 36,353], p = 0,0001] y shock séptico [OR: 3,224 [1,486, 6,994], p= 0,002) tuvieron un riesgo de muerte incrementado.

Conclusiones

Los pacientes mayores de COVID-19 con puntuaciones APACHE II más altas al ingreso, que desarrollaron IRA en grados ii o iii o shock séptico durante la estancia en UCI tuvieron un riesgo de muerte incrementado. La mortalidad en UCI fue del 31%.

Predictive and Comparative Study Between Clinic Consensus Document for Pancreas Acceptance and Predictive Value of Preprocurement Pancreas Allocation Suitability Score (P-PASS)

The strict selection of pancreas for transplant has forced the development of different documents to select the suitable organ in order to minimize the risks and complications of the transplant. In 2008, Eurotransplant published the Preprocurement Pancreas Allocation Suitability Score (P-PASS) for pretransplant selection. In 2001 the Hospital Clinic of Barcelona developed a Clinical Consensus Document (CCD).

OBJECTIVES

We aimed to analyze the predictive decision of the pancreas acceptance to offers received in the hospital, according to the CCD criteria and compare it with the recommended value of suitability for accepting the pancreas according to the P-PASS value.

MATERIAL AND METHODS

We performed a retrospective comparative study between the criteria of selection of the CCD for pancreas from 2016-2017 in comparison with the values obtained if the P-PASS had been used: ≤ 17, acceptance criteria and P-PASS; > 17, risk criteria. We defined the organ reported as rejected or accepted. The accepted organ could be procured and transplanted or discarded.

RESULTS

With the CCD criteria, 7 more organs were transplanted than if we only applied the potential P-PASS criteria. In contrast, P-PASS would have ruled out an additional 9% of pancreases in relation to CCD criteria.

CONCLUSIONS

According our experience, it is difficult to find an adequate prediction model to select pancreas for transplantation. The application of the DCC criteria increases the number of organs valid for transplantation. At present, new criteria should be re-evaluated within multicenter studies.

Relatives' Perception After Tissue Donation Experience: Results of a Postdonation Phone Survey

INTRODUCTION

Postmortem tissue donation (TD) requires the establishment of strategies for family approach to clearly explain the characteristics of multi-tissue donation. In a tertiary university hospital with a long tradition of tissue generation, we designed a survey to be applied to tissue donor families to evaluate global hospital care, care from Transplant Coordinators (TC), quality and content of information given about TD, experience, and motivations after TD process.

METHODOLOGY

A prospective phone survey of 10 multiple-choice items was conducted to all TD relatives that agreed to donate one or more tissues.

RESULTS

From the 166 calls made to TD relatives, 75 (45%) were answered: 50 were cornea donors and 25 were multiple-tissues donors. None of the relatives denied participating, the rest were not found. No statistical differences in demographical variables were found between both types of TD. The hospital and TC care perception, the quality of the given information about the processes of TD, the postdonation experiences in terms of procedures, and the impression about body appearance for relatives regardless of the type of donation, corneas or multiple tissues, were evaluated as good or very good for most of the TD relatives. Our study showed that 83% of the family members would agree to donate again; 40% of the relatives were surprised to be offered the option to donate; 10% did not know if they would donate again. Solidarity was the leading reason for TD.

CONCLUSION

The relatives' perception of care is a critical component of the quality evaluation of the TD process. The global evaluation results support our strategies for family approach.

Association of Brain-Dead Donors' Terminal Inflammation With Delayed Graft Function in Kidney Transplant Recipients

BACKGROUND

Systemic inflammation affects kidney function in a wide range of diseases. Even in kidney transplant recipients, higher levels of C-reactive protein (CRP) are invariably associated with both worse short- and long-term graft outcomes. However, little is known about systemic inflammation in kidney donors and, notably, brain death causes a strong systemic inflammatory response.

OBJECTIVE

To analyze the role of systemic inflammation of brain-dead donors on short-term kidney graft outcomes (ie, delayed graft function [DGF], defined as the need of dialysis during the first week after transplantation).

MATERIALS AND METHODS

Retrospective analysis of clinical and biochemical characteristics of all brain-dead kidney donors generated in the Hospital Clínic of Barcelona in the 2006 to 2015 period (n = 194). Donors who were tested for CRP in the 24 hours before BD declaration were included (n = 97, 50% of initial population). Clinical and biochemical features of their respective recipients (n = 165) were analyzed, comparing recipients who developed DGF (n = 30) with recipients who did not (n = 135).

RESULTS

Donors whose recipients later developed DGF had much higher CRP values (10.58 [5.1-18.21] vs 4.81 [1.42-12.2] mg/dL, P = .025). Other characteristics associated with the development of DGF were renal biopsy score and recipient dialysis vintage (P = .025 and P = .002, respectively). In logistic regression analysis, PCR maintained significance in the non-expanded criteria donor (ECD) group (odds ratio [OR], 1.102; P = .027), but it lost significance in the ECD group (P = .67).

CONCLUSIONS

Terminal donor CRP was associated with DGF in kidney transplant recipients and proved to be mostly significant in younger donors.

Successful Pancreas Transplantation From a Deceased Donor Intoxicated With Oral Antidiabetic Agent: A Case Report

Simultaneous kidney pancreas transplantation (SKP) is a common procedure for the patient with long-term type 1 diabetes mellitus (DM) with terminal renal failure. It is unusual to consider the pancreas from a deceased donor who died after an acute intoxication with oral antidiabetic agent (OAA), which would suggest an abnormal functionality of the organ and preclude the potential use of the graft. We present a case of a successful pancreatic transplantation from a donor who died of acute cerebral edema secondary to severe hypoglycemia induced by OAA acute intoxication.

Transient neurologic symptoms after spinal anaesthesia using isobaric 2% mepivacaine and isobaric 2% lidocaine

BACKGROUND

Transient Neurological Symptoms (TNS) syndrome following subarachnoid anaesthesia was initially associated with hyperbaric lidocaine 50 mg/ml, but has also been reported with most local anaesthetics, including hyperbaric mepivacaine 40 mg/ml. The aim of this study was to determine the incidence of TNS after subarachnoid anaesthesia using isobaric mepivacaine 20 mg/ml and isobaric lidocaine 20 mg/ml.

METHODS

Eighty patients of both sexes, ASA class I-II, scheduled for elective minor orthopaedic surgery under subarachnoid anaesthesia, were prospectively included and randomly allocated to receive 40-60 mg of either isobaric mepivacaine 20 mg/ml (Group M) or isobaric lidocaine 20 mg/ml (Group L). Patients were evaluated on the first postoperative day by one investigator unaware of the grouping, looking for symptoms suggestive of TNS, such as pain or dysaesthesias in the buttocks or lower limbs with or without back pain.

RESULTS

TNS symptoms were observed in three patients (7.5%) of Group M and in one patient (2.5%) of Group L, without statistically significant differences between the groups. Symptoms had an abrupt onset and relief, lasted from 45 min to 24 h, and had a complete resolution without sequelae. The only statistically significant difference between groups was longer motor blockade in Group M (P=0.0031).

CONCLUSION

In this study TNS was associated with isobaric mepivacaine 20 mg/ml, with an incidence of 7.5%, and with isobaric lidocaine 20 mg/ml, with an incidence of 2.5%, in patients having orthopaedic procedures in the supine position.

[Epidural hematoma after removal of an epidural catheter]

Epidural hematoma is a rare but serious neurological complication of epidural anesthesia. We report the case of a 61-year-old man with squamous cell carcinoma of the lung who suffered an epidural hematoma after undergoing right double lobectomy. Before anesthetic induction an epidural catheter was inserted to the D5-D6 space for postoperative analgesia. Surgery was without noteworthy events and the patient was extubated in the operating room; 5,000 IU of low molecular weight heparin was injected subcutaneously every 24 hours and 5 mg of methadone was provided by epidural catheter every 8 hours. After removal of the catheter three days after surgery, lumbar back pain and hypoesthesia, and weakness in both legs appeared. Epidural hematoma was suspected and treatment with 30 mg.kg-1 of methylprednisolone i.v. was started. Nuclear magnetic resonance imaging of the lumbar spine confirmed the presence of a hematoma at D6-D8. Neurologic symptoms improved in the following hours and additional surgery was not required. The patient was released without neurological symptoms 10 days after lung surgery. We discuss the prevalence, etiology and treatment of epidural hematoma related to epidural anesthesia.