Análisis del valor predictivo de los criterios de aislamiento preventivo en una unidad de cuidados intensivos / Analysis of the predictive value of preventive isolation criteria in the intensive care unit

Objetivo Evaluar la precisión diagnóstica de los criterios empleados para detectar al paciente realmente portador de microrganismos multirresistentes (MMR). Diseño Estudio prospectivo, observacional de mayo de 2014 a mayo de 2015. Ámbito Unidad de cuidados intensivos polivalente. Pacientes Cohorte de pacientes ingresados de forma consecutiva que cumplían los siguientes criterios de aislamiento preventivo basados en el proyecto «Resistencia Zero»: hospitalización de más de 4 días en los últimos 3 meses («hospital»); antibioterapia durante una semana en el último mes («antibiótico»), pacientes institucionalizados o en contacto con cuidados sanitarios («institución o cuidado»); portador de MMR los últimos 6 meses («MMR previo»). Variables Variables demográficas, resultados de los cultivos obtenidos con presencia o no de MMR y tiempo de aislamiento. Se realizó un análisis multivariable con regresión logística múltiple entre cada uno de los factores de riesgo y el que el paciente fuera portador de MMR. Resultados Durante el periodo de estudio ingresaron 575 pacientes y cumplieron los criterios de aislamiento un 28%. De los 162 pacientes con criterios 51 (31%) eran portadores de MMR y de los que no cumplían criterios 29 (7%) sí que eran portadores. En el análisis multivariable la única variable asociada de forma independiente con el ser portador fue «MMR previo», con una OR 12,14 (IC 95%: 4,24–34,77). Conclusiones El único criterio que se asoció de forma independiente con la capacidad de detectar los pacientes con MMR al ingreso en la UCI fue haber presentado un «MMR previo». (AU)

Objective To assess the diagnostic accuracy of the criteria used to detect patients carrying multiresistant microorganisms (MRMs). Design A prospective observational study was carried out from May 2014 to May 2015. Setting Polyvalent Intensive Care Unit. Patients A cohort of consecutively admitted patients meeting the following criteria for preventive isolation according to the “Zero Resistance” project: hospital length of stay>4 days in the last three months (“hospital”); antibiotherapy during one week in the last month (“antibiotic”); institutionalized patients or recurrent contact with healthcare (“institution or care”); MRM carrier in the last 6 months (“previous MRM”). Variables Demographic data, culture results and isolation time. A multivariate analysis was performed using multiple logistic regression between each of the risk factors and patient MRM carrier status. Results During the study period, 575 patients were admitted, of which 28% met the isolation criteria (162). Fifty-one (31%) were MRM carriers. Of the patients who did not meet the criteria, 29 (7%) were carriers. In the multivariate analysis, the only variable independently associated to carrier status was “previous MRM”, with OR=12.14 (95%CI 4.24-34.77). Conclusions The only criterion independently associated with the ability to detect patients with MRMs upon admission to the ICU was the existence of “previous MRM”. (AU)

[Analysis of the predictive value of preventive isolation criteria in the intensive care unit]. / Análisis del valor predictivo de los criterios de aislamiento preventivo en una unidad de cuidados intensivos.

OBJECTIVE: To assess the diagnostic accuracy of the criteria used to detect patients carrying multiresistant microorganisms (MRMs). DESIGN: A prospective observational study was carried out from May 2014 to May 2015. SETTING: Polyvalent Intensive Care Unit. PATIENTS: A cohort of consecutively admitted patients meeting the following criteria for preventive isolation according to the "Zero Resistance" project: hospital length of stay>4 days in the last three months ("hospital"); antibiotherapy during one week in the last month ("antibiotic"); institutionalized patients or recurrent contact with healthcare ("institution or care"); MRM carrier in the last 6 months ("previous MRM"). VARIABLES: Demographic data, culture results and isolation time. A multivariate analysis was performed using multiple logistic regression between each of the risk factors and patient MRM carrier status. RESULTS: During the study period, 575 patients were admitted, of which 28% met the isolation criteria (162). Fifty-one (31%) were MRM carriers. Of the patients who did not meet the criteria, 29 (7%) were carriers. In the multivariate analysis, the only variable independently associated to carrier status was "previous MRM", with OR=12.14 (95%CI 4.24-34.77). CONCLUSIONS: The only criterion independently associated with the ability to detect patients with MRMs upon admission to the ICU was the existence of "previous MRM".

Proyecto UCI sin paredes. Efecto de la detección precoz de los pacientes de riesgo / ICU without walls project. Effect of the early detection of patients at risk

Objetivos Describir y evaluar la repercusión de un sistema de detección e intervención precoz en pacientes de riesgo fuera de la UCI en la evolución de los pacientes ingresados en UCI y el número de paradas cardiorrespiratorias (PCR) hospitalarias. Ámbito Hospital de nivel 2 en la Comunidad de Madrid con historia clínica electrónica. Métodos Un intensivista revisa cada uno de los pacientes que cumplan los criterios de inclusión y decide la necesidad o no de intervención. Posteriormente, junto al médico a cargo del paciente, se determina cuál es el nivel de cuidados que necesita y se decide la pauta a seguir a continuación. Diseño Estudio descriptivo y cuasi-experimental «before-after». Resultados En el periodo de estudio se intervino en un total de 202 pacientes. Ciento cuarenta y siete fueron incluidos tras detectarse analíticas alteradas a través de nuestro programa informático. En el periodo de control la mortalidad en UCI fue 9 frente al 4,4% en el periodo de intervención (p=0,03). En el análisis multivariable, los 2 factores que guardaron relación significativa con la mortalidad fueron el haber ingresado durante el periodo de intervención OR 0,42 (IC95%; 0,18 a 0,98) (p=0,04) y el SAPS 3 OR 1,11 (IC95%; 1,07 a 1,14) (p<0,05). El número de avisos por PCR en el periodo control fue 10 frente 3 en el periodo de intervención (p=0,07).Conclusiones La actividad de detección precoz de pacientes en riesgo fuera de la UCI puede producir un efecto beneficioso sobre los pacientes ingresados en UCI así como una reducción de las PCR hospitalarias (AU)

Objectives To describe and evaluate the impact of a system for early detection and intervention in patients at risk outside the ICU upon the outcome of patients admitted to the ICU and the number of cases of hospital cardiopulmonary arrest. Setting A second-level hospital in the Community of Madrid (Spain) with electronic clinical histories Methods An intensivist reviewed each of the patients meeting the inclusion criteria, and decided the need or not for intervention. Posteriorly, in collaboration with the physician supervising the patient, the needed level of care was decided, along with the subsequent management protocol. Design A descriptive and quasi-experimental “before-after” study was made. Results A total of 202 patients were intervened during the study period, With the inclusion of 147 after detecting altered laboratory test results through our software application. During the control period, the mortality rate in the ICU was 9%, versus 4.4% during the intervention period (P=.03). In the multivariate analysis, the two factors significantly related to mortality were admission during the intervention period (OR=0.42; 95%CI: 0.18-0.98; P=.04) and SAPS 3 (OR=1.11; 95%CI: 1.07-1.14; P<0.05). There were 10 cardiopulmonary arrest alerts during the control period, versus three in the intervention period (P=.07).Conclusions Early detection activities in patients at risk outside the ICU can have beneficial effects upon the patients admitted to the ICU, and can contribute to reduce the number of hospital cardiopulmonary arrests (AU)

ICU without walls project. Effect of the early detection of patients at risk.

OBJECTIVES: To describe and evaluate the impact of a system for early detection and intervention in patients at risk outside the ICU upon the outcome of patients admitted to the ICU and the number of cases of hospital cardiopulmonary arrest. SETTING: A second-level hospital in the Community of Madrid (Spain) with electronic clinical histories. METHODS: An intensivist reviewed each of the patients meeting the inclusion criteria, and decided the need or not for intervention. Posteriorly, in collaboration with the physician supervising the patient, the needed level of care was decided, along with the subsequent management protocol. DESIGN: A descriptive and quasi-experimental "before-after" study was made. RESULTS: A total of 202 patients were intervened during the study period, With the inclusion of 147 after detecting altered laboratory test results through our software application. During the control period, the mortality rate in the ICU was 9%, versus 4.4% during the intervention period (P=.03). In the multivariate analysis, the two factors significantly related to mortality were admission during the intervention period (OR=0.42; 95%CI: 0.18-0.98; P=.04) and SAPS 3 (OR=1.11; 95%CI: 1.07-1.14; P<0.05). There were 10 cardiopulmonary arrest alerts during the control period, versus three in the intervention period (P=.07). CONCLUSIONS: Early detection activities in patients at risk outside the ICU can have beneficial effects upon the patients admitted to the ICU, and can contribute to reduce the number of hospital cardiopulmonary arrests.

Síndrome de distrés respiratorio agudo, ventilación mecánica y función ventricular derecha / Acute respiratory distress syndrome, mechanical ventilation and right ventricular function

La ventilación mecánica en el síndrome de distrés respiratorio agudo supone una elevación de la presión alveolar y transpulmonar que condiciona una alteración en la circulación pulmonar y supone una sobrecarga importante para la función del ventrículo derecho que puede fracasar dando lugar al cuadro clínico de cor pulmonale agudo. El cuadro se caracteriza ecográficamente por la dilatación del ventrículo derecho y por el movimiento paradójico del septo interventricular alterando también la función sistólica del ventrículo izquierdo. Es importante tener en cuenta la monitorización de la mecánica pulmonar y hemodinámica a la hora de plantear la estrategia ventilatoria de estos pacientes optimizando el reclutamiento pulmonar sin producir fenómenos de sobredistensión del pulmón que condicionen un mayor deterioro de la función del ventrículo derecho. Esta estrategia se ha denominado estrategia ventilatoria protectora del ventrículo derecho (AU)

Mechanical ventilation in acute respiratory distress syndrome (ARDS) implies an increase in alveolar and transpulmonary pressure, giving rise to major alterations in pulmonary circulation and causing right ventricular functional overload that can lead to ventricular failure and thus to acute cor pulmonale. The condition is echocardiographically characterized by dilatation of the right ventricle and paradoxical movement of the interventricular septum, with the added alteration of left ventricular systolic function. It is important to take lung mechanical and hemodynamic monitoring into account when defining the ventilation strategy in such patients, optimizing lung recruitment without producing pulmonary over-distension phenomena that may lead to greater deterioration of right ventricle function. This approach is known as a right ventricle protective ventilation strategy (AU)

[Acute respiratory distress syndrome, mechanical ventilation and right ventricular function]. / Síndrome de distrés respiratorio agudo, ventilación mecánica y función ventricular derecha.

Mechanical ventilation in acute respiratory distress syndrome (ARDS) implies an increase in alveolar and transpulmonary pressure, giving rise to major alterations in pulmonary circulation and causing right ventricular functional overload that can lead to ventricular failure and thus to acute cor pulmonale. The condition is echocardiographically characterized by dilatation of the right ventricle and paradoxical movement of the interventricular septum, with the added alteration of left ventricular systolic function. It is important to take lung mechanical and hemodynamic monitoring into account when defining the ventilation strategy in such patients, optimizing lung recruitment without producing pulmonary over-distension phenomena that may lead to greater deterioration of right ventricle function. This approach is known as a right ventricle protective ventilation strategy.