Influencia en la mortalidad según tiempo de ingreso en Unidad de Cuidados Intensivos: experiencia en el Hospital Clínico Regional Valdivia / Mortality according to time of admission to intenit: Hospital Clínico Regional Valdivia experiencesive care un

Introducción: La estructura organizacional de las Unidades de Cuidados Intensivos está basada en turnos, con cambios en los equipos durante la noche y los fines de semana-festivos (FdS-F). Se ha descrito una mayor mortalidad en los ingresos realizados durante estos períodos. Nuestro objetivo es evaluar si la mortalidad de los pacientes ingresados a nuestra unidad se ve influenciada porel horario nocturno o los FdS-F. Metodología: Estudio retrospectivo de la cohorte de pacientes ingresados desde el 1 de enero al 31 de diciembre de 2011 en el Hospital Clínico Regional Valdivia. Se consideró turno día (TD)el comprendido entre las 08:00 AM y las 20:59 PM, y el turno noche (TN) entre las 21:00 y las 07:59 horas. Se asignó como horario de fin de semana al comprendido entre el día viernes a las21:00 horas y el lunes a las 07:59. Dentro de esta misma categoría se incluyeron los festivos, con el mismo rango horario descrito. Base de datos en Excel MAC y análisis estadístico con Vassar Stats. Resultados: Durante el año 2011, se produjeron 425 ingresos, con una mortalidad global de 25 por ciento, variando según el tipo de patología que motivó el ingreso a la unidad (sepsis 45 por ciento, cardiovascular 17 por ciento, respiratorio 30 por ciento, neurológico 26 por ciento, trauma 24 por ciento, digestivo 32 por ciento, renal 14 por ciento, otras 18 por ciento). Los principales motivos de ingreso fueron las patologías cardiovasculares (32 por ciento), sepsis (18 por ciento) y enfermedades respiratorias (14 por ciento). El 51 por ciento requirió de Ventilación Mecánica Invasiva. El tiempo de estadía fue una mediana de 3 días (0-80). El 48 por ciento de los pacientes ingresó en el horario de TD, 38 por ciento en TN, sin contar con la hora de ingreso en el 14 por ciento de los casos. La mortalidad de los pacientes ingresados en TN fue 30 por ciento y los ingresados en TD 25 por ciento (OR 1,29 IC 95 por ciento 0,8126-2,0393; p= 0,29)...

Introduction: The job in most of Intensive Care Units (ICU) is organized in shift work, this system includes the activities performed during nights and weekends or holidays (W-HD). Higher mortality has been described in patients admitted at nights and W-HD. We decided to study if mortality in our unit was related to the admission during these periods. Methods: We reviewed the clinical records of patients admitted at the ICU of Valdivia Hospital since January 31, 2011 to December 31, 2011. Day shift (DS) was defined between 8:00 and 20:59 hours, night shift (NS) between 21:00 and 7:59 hours, weekend was considered as the period between Friday at 21:00hours and Monday at 7:59 and finally, holiday was considered as the period between the previous date at 21:00 and next day at 7:59 hours of a non-laboral day. Data were analyzed with Microsoft EXCEL for Mac and Vassar stats software. Results: four hundred twenty five patients were admitted at the ICU during this period, the mortality was 25 percent. It was different according with type of disease (sepsis 45 percent, cardiovascular disease 17 percent, respiratory disease 30 percent, neurologic disease 26 percent, trauma 24 percent, gastrointestinal disease 32 percent, renal disease 14 percent, others 18 percent). The most frequent causes of admission were cardiovascular diseases (32 percent), sepsis (19 percent) and respiratory diseases (14 percent). 51 percent of patients were submitted to mechanical ventilation. The median of staying in the unit was 3 days (0-80 days). 48 percent of patients were entered at the unit at DS, 38 percent at NS and in 14 percent of cases the time of admission was not registered. Mortality of patients admitted was 30 percent in NS and 25 percent in DS (OR 1,29 CI 95 percent 0,8126-2,0393; p=0,29)...

Utilidad clínica de los hemocultivos en pacientes hospitalizados por neumonía adquirida en la comunidad / Clinical usefulness of blood cultures in hospitalized patients with community acquired pneumonia

Background: The clinical role of blood cultures (BC) in the management of hospitalized patients with community-acquired pneumonia (CAP) is controversial. Aim: To evaluate the clinical usefulness of blood cultures in CAP. Material and methods: We prospectively studied 244 immunocompetent adults with two or more BC obtained at admission. The diagnostic yield of BC and its impact on antibiotic therapy were assessed. Results: Mean age (xñsd) of patients was 67ñ20 years, 80 percent had underlying diseases and 29 percent received antibiotics prior to admission. Hospital length of stay was 10.4ñ10 days and global mortality was 7 percent. The diagnostic yield of BC was only 8.2 percent (20 patients). Mortality was significantly higher in patients with positive BC (20 percent) than in those with negative BC (5.8 percent). In only one of the 20 patients with positive BC (0.4 percent of total study population), attending physicians changed empiric antimicrobial therapy based on these results. Conclusions: This study confirms that the diagnostic yield of BC in CAP hospitalized patients is low, that mortality in bacteremic patients is high and suggests that clinical usefulness of BC to guide changes on empiric antimicrobial therapy is limited, in part because attending physicians seldom use such information

Inmunogenicidad de una vacuna recombinante anti hepatitis B en personal de salud / Immune response to hepatitis B vaccine in health care workers

El virus de hepatitis B (HB) es capaz de persistir en un porcentaje de los infectados produciendo enfermedad hepática crónica a largo plazo. El personal de salud es un grupo especialmente expuesto a contraer esta infección. Actualmente se dispone de vacunas HB inmunogénicas, eficaces y seguras. Aunque la mayoría de las personas responde de una forma adecuada, un porcentaje bajo no son respondedores. Con el objeto de evaluar la respuesta inmune a una vacuna recombinante e identificar potenciales factores de riesgo de una respuesta inadecuada, se realizó un estudio prospectivo en funcionarios de la salud. A los 6 meses de recibir 3 dosis de vacuna contra HB (0-1-6 meses) se les midió título de anticuerpos contra antígeno de superficie de hepatitis B (anti HBs). Se estudiaron 485 sujetos con una relación mujer: hombre de 2.6:1 y una edad promedio de 35.8 años. De los 485, 409 (84.3 por ciento) funcionarios presentaron niveles mayores de 100 mUI/ml, 55 (11.3 por ciento) mostraron niveles entre 10 y 100 mUI/ml y 21 (4.3 por ciento) bajo 10 mUI/ml (4.3 por ciento). Un análisis multivariado de estos 3 grupos mostró que a mayor edad, los niveles de anti HBs eran menores (p< 0.01). No se encontró esta asociación con sexo e índice de masa corporal. Estos resultados muestran una adecuada inmunogenicidad de la vacuna recombinante ya que 95.7 por ciento de los individuos vacunados presentó niveles anti HBs considerados como protectores (> 10 mUI/ml)

Estudio de la cinética de citoquinas en sepsis grave y su relación con mortalidad y score de disfunción orgánica / Cytokine kinetics in severe sepsis: its relationship with mortality and organic dysfunction

Background: The Infectious Systemic Inflammatory Response syndrome and multiple organic dysfunction have common physiopathological mechanisms. Multiple organic dysfunction can be assessed using severity scores. Aim: To relate cytokine kinetics with a multiple organic dysfunction score during sepsis. Material and methods : Tumor necrosis factor a (TNFa) and interleukin 6 (IL6) kinetics were studied in 25 patients with severe sepsis with less than 48 h of evolution and interleukin 1ß (ILß) kinetics was studied in 13 patients. Measurements were made at 0, 12, 24 and 48 hours after admission to the study, using an ELISA technique. These parameters were correlated with the Marshall multiple organic dysfunction score and survival. Results: Mean age of study subjects was 70 years, the APACHE II score was 16.9ñ6 and the Marshall score was 6.8ñ3.6. Sepsis was of pulmonary origin in 56 percent of patients and intra abdominal in 32 percent. Mortality was 36 percent. TNFa increased during the study period (24.1 pg/ml initially and 37.8 pg/ml at 24 hours, with a slight posterior reduction, p<0.02). These levels had no association with mortality or organic dysfunction. IL6 remained elevated during the first hours and had a tendency to decrease thereafter. Deceased patients had higher values than survivors (306 pg/ml and 55.4 pg/ml respectively, p=0.011). Its values were tightly correlated with Marshall score, with the number of failing organs, with the presence of shock and with probability of dying during hospitalization. IL1ß remained low and was not associated with clinical parameters. Conclusions: There is a tight correlation between the elevation of IL6 and the severity of the Systemic Inflammatory Response and mortality in these patients with sepsis

Tratamiento de la neumonía asociada a ventilación mecánica / Treatment of pneumonia associated to mechanical ventilator

Ventilator-associated pneumonia is a life-threatening disease causing an increased morbidity, mortality, cost and length of stay in the intensive care unit. Inappropriate treatment is frequent and it is associated with worse prognosis. This document is an evidence based consensus which discusses treatment aspects of this complication. Empiric treatment should be based on local epidemiology and data collected through the national nosocomial infection surveillance and reliable microbiology. Antibiotic treatment on specific microorganisms is also recommended

Prevención de la neumonía asociada a ventilación mecánica / Prevention of pneumonia associated to mechanical ventilator

Ventilator-associated pneumonia is a life-threatening disease causing an increased morbidity, cost and length of stay in the intensive care unit. This document is an evidence based consensus which discusses preventive measures including medical recommendations and practices for cleaning and handling mechanical ventilators. Standard and contact precautions are critical preventive measures