Respuesta de los autores: Epidemiología de la sepsis en los servicios de urgencias / Author's reply: Epidemiology of sepsis in the emergency care department

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Epidemiología y factores pronósticos de la sepsis grave/shock séptico. Seis años de evolución / Epidemiology and prognostic factors in severe sepsis/septic shock. Evolution over six years

OBJETIVO: Examinar las características clínicas y los factores pronósticos de los pacientes ingresados por sepsis grave/shock séptico en la Unidad de Cuidados Intensivos del Hospital Universitario Donostia. DISEÑO: Estudio observacional prospectivo durante un período consecutivo de 6 años (1-2-2008 a 31-12-2013). ÁMBITO: Servicio de Medicina Intensiva del Hospital Universitario Donostia, único hospital terciario de Guipúzcoa. RESULTADOS: El número de pacientes con sepsis grave/shock séptico ha aumentado progresivamente hasta un total de 1.136, sin observarse cambios significativos en la edad, el sexo, la puntuación del Acute Physiology and Chronic Health Evaluation II, los valores de procalcitonina ni en los de lactato sérico. En los últimos años ha habido un aumento significativo de los ingresos desde Urgencias respecto a los procedentes de planta, con una mayor incidencia de la sepsis urológica. La afectación hemodinámica y renal han sido las disfunciones más prevalentes, descendiendo la afectación respiratoria y la trombocitopenia y aumentando la coagulopatía. La mortalidad ha descendido significativamente. Mediante un análisis multivariante analizamos factores pronósticos precoces: el tipo de paciente, su procedencia, la etiología de la sepsis, la cifra de lactato y la presencia de disfunciones orgánicas, exceptuando la hiperbilirrubinemia y la hipotensión, fueron las variables más influyentes en la mortalidad. CONCLUSIONES: La sepsis grave/shock séptico genera un creciente número de ingresos. A pesar de que las características clínicas han variado poco en los últimos años, hemos observado un descenso de la mortalidad. Consideramos importante el conocimiento de los factores pronósticos precoces para mejorar el abordaje de estos pacientes

OBJECTIVE: To determine the clinical characteristics and prognostic factors of patients with severe sepsis/septic shock admitted to the Intensive Care Unit of Donostia University Hospital (Guipuzcoa, Spain). DESIGN: A prospective, observational study was carried out during a consecutive 6-year period (1st February 2008-31st December 2013). SETTING: The Intensive Care Unit of Donostia University Hospital, the only third level hospital in the province of Guipuzcoa, with a recruitment population of 700,000 inhabitants. RESULTS: Number of patients with severe sepsis/septic shock has progressively increased over the last years to reach 1,136 patients, yet significant changes in age, sex, Acute Physiology and Chronic Health Evaluation II, procalcitonin and lactate values could not be observed. In the last years, admission rate from Emergency Department has increased in comparison to admissions from hospitalization ward, with a higher incidence of urological sepsis. Hemodynamic and renal dysfunctions have been the most prevalent disorders, respiratory involvement and thrombocytopenia have gone down while coagulopathy has increased significantly. Mortality has decreased significantly. We have performed a multivariate analysis of the early prognostic factors. Type, origin, sepsis etiology, lactate and the presence of organ dysfunction -except for hyperbilirubinemia and hypotension- were the most important mortality factors. CONCLUSIONS: Severe sepsis and septic shock result in growing ICU admissions. Although clinical features have barely changed over the last years, we have observed a decrease in mortality. We find important knowing these early prognostic factors to improve the management of these patients

Epidemiology and prognostic factors in severe sepsis/septic shock. Evolution over six years.

OBJECTIVE: To determine the clinical characteristics and prognostic factors of patients with severe sepsis/septic shock admitted to the Intensive Care Unit of Donostia University Hospital (Guipuzcoa, Spain). DESIGN: A prospective, observational study was carried out during a consecutive 6-year period (1st February 2008-31st December 2013). SETTING: The Intensive Care Unit of Donostia University Hospital, the only third level hospital in the province of Guipuzcoa, with a recruitment population of 700,000 inhabitants. RESULTS: Number of patients with severe sepsis/septic shock has progressively increased over the last years to reach 1,136 patients, yet significant changes in age, sex, Acute Physiology and Chronic Health Evaluation II, procalcitonin and lactate values could not be observed. In the last years, admission rate from Emergency Department has increased in comparison to admissions from hospitalization ward, with a higher incidence of urological sepsis. Hemodynamic and renal dysfunctions have been the most prevalent disorders, respiratory involvement and thrombocytopenia have gone down while coagulopathy has increased significantly. Mortality has decreased significantly. We have performed a multivariate analysis of the early prognostic factors. Type, origin, sepsis etiology, lactate and the presence of organ dysfunction -except for hyperbilirubinemia and hypotension- were the most important mortality factors. CONCLUSIONS: Severe sepsis and septic shock result in growing ICU admissions. Although clinical features have barely changed over the last years, we have observed a decrease in mortality. We find important knowing these early prognostic factors to improve the management of these patients.

Registro observacional y prospectivo de sepsis grave/shock séptico en un hospital terciario de la provincia de Guipúzcoa / A prospective, observational severe sepsis/septic shock registry in a tertiary hospital in the province of Guipuzcoa (Spain)

Objetivo: Conocer las características epidemiológicas y clínicas de los pacientes con sepsis grave/shock séptico ingresados en la unidad de cuidados intensivos del Hospital Donostia, analizar factores pronósticos y compararlos con los datos existentes a nivel nacional. Diseño: Estudio observacional prospectivo durante un periodo consecutivo de 3 años (1 de febrero de 2008-31 de diciembre de 2010). Ámbito: Unidad de cuidados intensivos (UCI) del Hospital Donostia, único hospital de tercer nivel de la provincia de Guipúzcoa, que atiende a una población de 700.000 habitantes. Resultados: A lo largo de este periodo, 6.263 pacientes ingresaron en nuestro servicio; 2.880 fueron pacientes no coronarios y 511 presentaron al ingreso o en su evolución en UCI, un episodio de sepsis grave o shock séptico. Hubo un predominio de varones (66,5%), con una edad media de 63 años y Acute Physiology And Chronic Health Evaluation II (APACHE II) medio de 21. La mayoría fueron de tipo médico (68%), procedentes de planta de hospitalización(53,5%) y el origen más frecuente fue la neumonía (24%). La gran mayoría (73%) presentó shock séptico. La afectación hemodinámica fue la más frecuente, seguida de la renal y respiratoria. En todos los pacientes con shock se utilizó noradrenalina como vasopresor, más de la mitad requirieron ventilación mecánica (VM) y un tercio, hemodiafiltración venovenosa continua (HDFVVC). En el manejo de estos (..)(AU)

Objective: To determine the epidemiological and clinical characteristics of the patients with severe sepsis/septic shock admitted to the ICU of Donostia Hospital (Guipuzcoa, Spain), analyzing the prognostic factors and comparing them with the existing data at national level. Design: A prospective observational study was carried out during a consecutive 3-year period (1 Feb. 2008-31 Dec. 2010). Setting: The ICU of Donostia Hospital, the only third level hospital in the province of Guipúzcoa, with a recruitment population of 700,000 inhabitants. Results: In the course of the study period, 6,263 patients were admitted to our Department: 2,880 were non-coronary patients, and 511 suffered a severe sepsis or septic shock episode upon admission or during their stay in the ICU. Males predominated (66.5%), the mean age was 63 years, and the mean Acute Physiology And Chronic Health Evaluation II (APACHE II) score was 21. Most cases were medical (68%) and were admitted from hospital wards (53.5%). The most frequent origin was pneumonia (24%). The great majority of the cases (73%) corresponded to septic shock. Hemodynamic alterations were the most frequent disorders, followed by renal and respiratory impairment. Noradrenalin was used as vasoactive drug in all shock patients; over one-half required mechanical ventilation (MV), and one third required continuous venous-venous hemodiafiltration (CVVHDF). Interventions frequently used in the management of these patients comprised blood cultures or corticosteroid use, while other measures such as activated protein C were little used. The mortality rate in the ICU was 20.8%, with a mean stay in the Unit of 14 days. The parameters associated to mortality in the multivariate analysis included the presence of hypoglycemia, respiratory dysfunction, the need for MV, lactic acid elevation and (..) (AU)

[A prospective, observational severe sepsis/septic shock registry in a tertiary hospital in the province of Guipuzcoa (Spain)]. / Registro observacional y prospectivo de sepsis grave/shock séptico en un hospital terciario de la provincia de Guipúzcoa.

OBJECTIVE: To determine the epidemiological and clinical characteristics of the patients with severe sepsis/septic shock admitted to the ICU of Donostia Hospital (Guipuzcoa, Spain), analyzing the prognostic factors and comparing them with the existing data at national level. DESIGN: A prospective observational study was carried out during a consecutive 3-year period (1 Feb. 2008-31 Dec. 2010). SETTING: The ICU of Donostia Hospital, the only third level hospital in the province of Guipúzcoa, with a recruitment population of 700,000 inhabitants. RESULTS: In the course of the study period, 6,263 patients were admitted to our Department: 2,880 were non-coronary patients, and 511 suffered a severe sepsis or septic shock episode upon admission or during their stay in the ICU. Males predominated (66.5%), the mean age was 63 years, and the mean Acute Physiology And Chronic Health Evaluation II (APACHE II) score was 21. Most cases were medical (68%) and were admitted from hospital wards (53.5%). The most frequent origin was pneumonia (24%). The great majority of the cases (73%) corresponded to septic shock. Hemodynamic alterations were the most frequent disorders, followed by renal and respiratory impairment. Noradrenalin was used as vasoactive drug in all shock patients; over one-half required mechanical ventilation (MV), and one third required continuous venous-venous hemodiafiltration (CVVHDF). Interventions frequently used in the management of these patients comprised blood cultures or corticosteroid use, while other measures such as activated protein C were little used. The mortality rate in the ICU was 20.8%, with a mean stay in the Unit of 14 days. The parameters associated to mortality in the multivariate analysis included the presence of hypoglycemia, respiratory dysfunction, the need for MV, lactic acid elevation and thrombocytopenia in the first 24 hours, together with an origin of sepsis either in the ICU or in the hospital. CONCLUSIONS: Severe sepsis is frequent in our unit, generating important morbidity and hospital stay, as well as high mortality. The epidemiological and clinical characteristics of our patients are similar to those described globally at national level. Considering our data in complying with the different treatment measures, it is clear that there is still room for improvement.

Pileflebitis secundaria a diverticulitis / Pylephlebitis secondary to diverticulitis

La pileflebitis o trombosis infecciosa de la vena porta es una complicación poco frecuente pero grave de algunas infecciones intraabdominales. La etiología es normalmente polimicrobiana. Debido a la inespecificidad de la clínica, el diagnóstico se puede retrasar empeorando así el pronóstico de la enfermedad. Técnicas de imagen como la ecografía o la tomografía axial computarizada han sido de gran ayuda en el diagnóstico de esta entidad. La antibioterapia de amplio espectro constituye el tratamiento de elección, siendo controvertido el papel de la anticoagulación. Presentamos el caso de un paciente con pileflebitis secundaria a diverticulitis (AU)