Structural control of the non-ionic surfactant alcohol ethoxylates (AEOs) on transport in natural soils.

Surfactants, after use, enter the environment through diffuse and point sources such as irrigation with treated and non-treated waste water and urban and industrial wastewater discharges. For the group of non-ionic synthetic surfactant alcohol ethoxylates (AEOs), most of the available information is restricted to the levels and fate in aquatic systems, whereas current knowledge of their behavior in soils is very limited. Here we characterize the behavior of different homologs (C12-C18) and ethoxymers (EO3, EO6, and EO8) of the AEOs through batch experiments and under unsaturated flow conditions during infiltration experiments. Experiments used two different agricultural soils from a region irrigated with reclaimed water (Guadalete River basin, SW Spain). In parallel, water flow and chemical transport were modelled using the HYDRUS-1D software package, calibrated using the infiltration experimental data. Estimates of water flow and reactive transport of all surfactants were in good agreement between infiltration experiments and simulations. The sorption process followed a Freundlich isotherm for most of the target compounds. A systematic comparison between sorption data obtained from batch and infiltration experiments revealed that the sorption coefficient (Kd) was generally lower in infiltration experiments, performed under environmental flow conditions, than in batch experiments in the absence of flow, whereas the exponent (ß) did not show significant differences. For the low clay and organic carbon content of the soils used, no clear dependence of Kd on them was observed. Our work thus highlights the need to use reactive transport parameterization inferred under realistic conditions to assess the risk associated with alcohol ethoxylates in subsurface environments.

Soporte con oxigenación de membrana extracorpórea en un síndrome de Takotsubo y QT largo tras cirugía cardiaca / Extracorporeal membrane oxygenation support for Takotsubo syndrome and long QT after cardiac surgery

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Relationship between functional status prior to onset of critical illness and mortality: a prospective multicentre cohort study.

This prospective study aimed to assess the association between prior functional status and hospital mortality for patients admitted to four intensive care units in Spain between 2006 and 2012. Prior functional status was classified into three groups, using a modification of the Glasgow Outcome Scale (GOS), including group 1 with no limitations on activities of daily living; group 2 with some limitations but self-sufficient; and group 3 who were dependent on others for their activities of daily living. Of the 1,757 patients considered (mean Simplified Acute Physiology Score [SAPS] predicted mortality 14.8% and hospital mortality 13.7%), group 1 had the lowest observed hospital mortality (8.3%) compared to the SAPS 3 predicted mortality (11.6%). The observed mortality for group 2 (20.6%) and group 3 (27.4%) were both higher than predicted (19.2% and 21.2% respectively; odds ratio [OR] 1.97, 95% confidence interval [CI] 1.38-2.82 for group 2 and OR 2.90, 95% CI 1.78-4.72 for group 3 compared to group 1). Combining prior functional status and Sequential Organ Failure Assessment (SOFA) score with SAPS 3 further improved the ability of the SAPS 3 scores in predicting hospital mortality (area under the receiver operating characteristic curve 0.85 [95% CI 0.82-0.88] versus 0.84 [95% CI 0.81-0.87] respectively). In summary, patients with limited functional status prior to ICU admission had a higher risk of observed hospital mortality than predicted. Assessing prior functional status using a relatively simple questionnaire, such as a modified GOS, has the potential to improve the accuracy of existing prognostic models.

Respuesta de los autores: Electrocardiogramas en un paciente diabético con síndrome de tako-tsubo tras cirugía cardíaca para mixoma auricular / Author's reply: Electrocardiograms in a diabetic patient with takotsubo syndrome after heart surgery for atrial myxoma

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Hipoxemia grave por shunt intracardiaco secundario a trombosis de prótesis tricuspídea / Severe hypoxemia due to intracardiac shunting secondary to thrombosis of a tricuspid valve prosthesis

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Efficacy of an extravascular lung water-driven negative fluid balance protocol

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI > 9 ml/kg. The protocol dictates a negative fluid balance between 500 and 1500 ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210 mmHg (IQR 164, 248) (p < 0.001), and EVLWI decreased from 14 (11, 18) to 10 ml/kg (8, 14) (p < 0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10 ml/kg (8, 14) at the end of the protocol (p = 0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216 mmHg (IQR 137, 260) at the beginning versus 205 mmHg (IQR 99,257) at the end of the study (p = 0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group

OBJETIVO: Analizar la eficacia del balance hídrico negativo en pacientes hipoxémicos y con Agua Pulmonar Extravascular Indexada (EVLWI) elevada. Diseño: Estudio retrospectivo y observacional. ÁMBITO: Unidad de Cuidados Intensivos del Hospital Virgen de las Nieves. Participantes: 44 pacientes. Intervenciones: Se analizó la base de datos de pacientes hipoxémicos durante 11 meses consecutivos. Se incluyeron los pacientes hipoxémicos, hemodinámicamente estables y con EVLWI > 9 ml/kg. El protocolo dicta un balance hídrico negativo entre 500 y 1500 ml/día. Se analizó el impacto de esta estrategia de balance negativo en la función respiratoria, hemodinámica y renal. Variables de interés principales: Datos demográficos, escalas de gravedad y datos clínicos hemodinámicos, respiratorios, metabólicos y de función renal. RESULTADOS: 33 pacientes lograron balance hídrico negativo (Grupo BHN) y 11 tuvieron balance hídrico positivo (Grupo BHP). En el grupo BHN la PaO2/FiO2 pasó de 145 (IQR 106,200) a 210 (IQR 164, 248) mmHg (p < 0.001), el EVLWI descendió de 14 (11, 18) a 10 (8, 14) ml/kg (p < 0.001). En el grupo BHP, el EVLWI también descendió de 11(10, 14) a 10 (8, 14) ml/kg al final del protocolo (p = 0.004); en este último grupo no hubo cambios estadísticamente significativos en la oxigenación y la PaO2/FiO2 pasó de 216 (IQR 137, 260) a 205 (IQR 99, 257) mmHg (p = 0.08). CONCLUSIÓN: Tres de cada cuatro pacientes hipoxémicos y con EVLWI elevados toleraron el protocolo; en ellos, la mejora de diversos parámetros analizados fue mayor y más rápida que en los pacientes que no hicieron balance negativo. Los pacientes que no toleraron el protocolo fueron los más graves aunque se necesitaría una muestra mayor para determinar las características específicas en estos

Preoperative use of statins does not improve outcomes and development of acute renal failure after cardiac surgery. A propensity score analysis of ARIAM-Andalucía database.

BACKGROUND: Statin use prior to cardiac surgery has been reported to improve outcomes in the postoperative period because of other effects apart from decreasing lipid levels. Objective of the study was to analyse mortality and acute renal failure (ARF) during the cardiac surgery postoperative period in patients treated with or without statins. METHODS: This prospective cohort study comprised adult patients who underwent cardiac surgery at 11 institutions in the Andalusian community from March 2008 to July 2012 included in the ARIAM adult cardiac surgery project. We performed a first analysis in the whole cohort and in a second analysis statin users prior to surgery were pair matched with non-users according to their propensity score based on demographics, comorbidities, medication and surgical data. We analysed differences in outcomes, ARF, need for renal replacement therapy (RRT) and a composite end point with mortality or major morbidity in both groups. RESULTS: The study included 7276 patients, of whom 3749 were treated with statins. Overall, hospital mortality was 10.1%, 10.5% developed ARF and 2.5% required RRT. In the whole non-matched cohort, statins were associated with lower hospital mortality (OR 0.79; 95% CI, 0.67-0.93) and less ARF (OR 0.79; 95% CI, 0.68-0.93). However, after propensity score analysis in the matched cohort of 3056 patients (1528 in each group), statin use was not consistently associated with less ARF (OR 0.94; 95% CI, 0.74-1.19), hospital mortality (OR 0.83; 95% CI, 0.68-1.1) or composite outcome (OR 0.857; 95% CI, 0.723-1.015). CONCLUSION: Despite better outcomes for the statin users in the whole cohort, the matched analysis showed that statin use before cardiac surgery was not associated with a lower risk of ARF. Nor was presurgery statin use associated with lower hospital mortality.

Efficacy of an extravascular lung water-driven negative fluid balance protocol.

OBJECTIVE: To analyze the efficacy of negative fluid balance in hypoxemic patients with an elevated extravascular lung water index (EVLWI). DESIGN: A retrospective observational study was made. SETTING: Intensive Care Unit of Virgen de las Nieves Hospital (Spain). PARTICIPANTS: Forty-four patients participated in the study. INTERVENTIONS: We analyzed our database of hypoxemic patients covering a period of 11 consecutive months. We included all hemodynamically stable and hypoxemic patients with EVLWI>9ml/kg. The protocol dictates a negative fluid balance between 500 and 1500ml/day. We analyzed the impact of this negative fluid balance strategy upon pulmonary, hemodynamic, and renal function. MAIN VARIABLES OF INTEREST: Demographic data, severity scores, clinical, hemodynamic, pulmonary, metabolic and renal function data. RESULTS: Thirty-three patients achieved negative fluid balance (NFB group) and 11 had a positive fluid balance (PFB group). In the former group, PaO2/FiO2 improved from 145 (IQR 106, 200) to 210mmHg (IQR 164, 248) (p<0.001), and EVLWI decreased from 14 (11, 18) to 10ml/kg (8, 14) (p<0.001). In the PFB group, EVLWI also decreased from 11 (10, 14) to 10ml/kg (8, 14) at the end of the protocol (p=0.004). For these patients there were no changes in oxygenation, with a PaO2/FiO2 of 216mmHg (IQR 137, 260) at the beginning versus 205mmHg (IQR 99,257) at the end of the study (p=0.08). CONCLUSION: Three out of four hypoxic patients with elevated EVLWI tolerated the NFB protocol. In these subjects, the improvement of various analyzed physiological parameters was greater and faster than in those unable to complete the protocol. Patients who did not tolerate the protocol were usually in more severe condition, though a larger sample would be needed to detect specific characteristics of this group.

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. Patients and setting: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. Measurements and results: A total of 2171 patients were included in the study. The mean age was 61.4 ± 16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29 ± 14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H = 31.71 (p < 0.05) for our geographical area and H = 20.05 (p < 0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness

OBJETIVO: Analizar el funcionamiento del sistema SAPS3 en España, evaluando la discriminación y calibración en un estudio multicéntrico. DISEÑO: Estudio prospectivo de cohortes, multicéntrico. Ámbito: Hospitales españoles entre 2006 y 2011. Variables de interés y resultados: Se incluyó en el estudio a un total de 2171 pacientes. La edad media fue 61,4 ± 16,09 años, la mortalidad en UCI fue del 11,6% y la mortalidad hospitalaria 16,03%. El score SAPS 3 fue de 46,29 ± 14,34 puntos, con la probabilidad de morir por la ecuación de nuestra área geográfica 18.57%, y 17.97% para la ecuación general. Las diferencias entre la mortalidad observada y la predicha se analizaron mediante el test de Hosmer-Lemeshow. Este test mostró H = 31,71 (p < 0,05) para nuestra área geográfica y H = 20,05 (p < 0,05) para la ecuación general. La discriminación del SAPS 3 con respecto a la mortalidad hospitalaria, testada mediante el área bajo la curva ROC, fue 0.845 (0,821-0,869). CONCLUSIÓN: Nuestro estudio muestra, en España, una buena discriminación del sistema pronóstico SAPS 3 pero una inadecuada calibración, con diferencias entre la mortalidad predicha y, la observada. Hay más similitudes con respecto a la ecuación general que con la ecuación de nuestra zona geográfica, y en ambos casos, el sistema SAPS 3 sobreestima la mortalidad. De acuerdo con los resultados, la mortalidad en UCI es menor que la de otros hospitales incluidos en el estudio multicéntrico que se utilizaron para desarrollar el sistema SAPS 3, en pacientes con similares características y severidad de la enfermedad

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain.

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. PATIENTS AND SETTING: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. MEASUREMENTS AND RESULTS: A total of 2171 patients were included in the study. The mean age was 61.4±16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29±14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H=31.71 (p<0.05) for our geographical area and H=20.05 (p<0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness.

Utilidad de la ecografía pulmonar en la unidad de medicina intensiva / Utility of the lung ultrasound in the intensive medicine unit

Tradicionalmente, el abordaje diagnóstico por la imagen del tórax en el paciente crítico se ha basado en la radiografía simple anteroposterior. Sin embargo, esta presenta grandes limitaciones en la precisión diagnóstica de la enfermedad pleuropulmonar. La introducción de la tomografía axial computarizada resolvió en gran medida este problema, pero con el doble inconveniente de las dosis de radiación y del inevitable traslado fuera de la unidad de cuidados intensivos. En este contexto, la ecografía pulmonar, gracias a su portabilidad, se convierte en una técnica alternativa en determinadas situaciones, con la ventaja de realizarse a la cabecera de los pacientes, ser fácilmente reproducible y no administrar radiaciones ionizantes. En la ecografía pulmonar, las costillas, la columna vertebral y el aire del pulmón actúan como barreras para los ultrasonidos, y provocan artefactos que debemos reconocer e interpretar para un correcto diagnóstico. No obstante, las enfermedades intratorácicas y la existencia de líquido en el espacio pleural, así como la consolidación o atelectasia en el pulmón proporcionan suficiente ventana ecográfica para una correcta evaluación. En la siguiente revisión abordaremos los aspectos principales de la realización de la técnica de la ecografía pulmonar, definiremos el patrón normal y los artefactos que sirven de base para la detección de anormalidades, y explicaremos los criterios de los patrones de las principales enfermedades (consolidación, derrame pleural, edema de pulmón y neumotórax). También discutiremos la posible utilidad y las limitaciones que la ecografía pulmonar puede tener en diferentes situaciones de nuestra práctica clínica, como en el diagnóstico de la insuficiencia respiratoria aguda; la detección, la cuantificación y el drenaje del derrame pleural; el traumatismo torácico; las complicaciones y el tratamiento del sídrome de distrés respiratorio agudo, y la comprobación de una correcta intubación traqueal (AU)

The radiological diagnostic approach of the thorax in the critically ill patient has traditionally been based on the anteroposterior chest X-ray. However, it is generally accepted that it has important limitations regarding its diagnostic accuracy of pleuro-pulmonary disease. The introduction of computed tomography largely solved this problem, but with the dual disadvantage of a larger radiation dose and the unavoidable transportation outside of the ICU. In this context, the lung ultrasound has become an alternative technique, with the advantage that due to its portability, it is done at the patient's bedside. In the lung ultrasound, the ribs, spine and air in the thorax act as barriers to the ultrasounds, causing artifacts that must be recognized and interpreted for a correct diagnosis. However, intrathoracic diseases, existence of fluid in the pleural space and consolidation, or atelectasis in the lung provide a sufficient ultrasound window for the correct evaluation. In this review, we explain the lung and pleural ultrasound technique, define the normal pattern and the artifacts that serve to detect the abnormalities and we explain the criteria for the main diseases (consolidation, pleural effusion, pulmonary edema and pneumothorax). We also discuss the possible utility and limitations of the lung ultrasound in our daily practice, such as diagnosis of acute respiratory failure, detection, quantification and drainage of a pleural effusion, chest trauma, management and complications of acute respiratory distress syndrome and tracheal intubation success or failure (AU)

[Utility of the lung ultrasound in the intensive medicine unit]. / Utilidad de la ecografía pulmonar en la unidad de medicina intensiva.

The radiological diagnostic approach of the thorax in the critically ill patient has traditionally been based on the anteroposterior chest X-ray. However, it is generally accepted that it has important limitations regarding its diagnostic accuracy of pleuro-pulmonary disease. The introduction of computed tomography largely solved this problem, but with the dual disadvantage of a larger radiation dose and the unavoidable transportation outside of the ICU. In this context, the lung ultrasound has become an alternative technique, with the advantage that due to its portability, it is done at the patient's bedside. In the lung ultrasound, the ribs, spine and air in the thorax act as barriers to the ultrasounds, causing artifacts that must be recognized and interpreted for a correct diagnosis. However, intrathoracic diseases, existence of fluid in the pleural space and consolidation, or atelectasis in the lung provide a sufficient ultrasound window for the correct evaluation. In this review, we explain the lung and pleural ultrasound technique, define the normal pattern and the artifacts that serve to detect the abnormalities and we explain the criteria for the main diseases (consolidation, pleural effusion, pulmonary edema and pneumothorax). We also discuss the possible utility and limitations of the lung ultrasound in our daily practice, such as diagnosis of acute respiratory failure, detection, quantification and drainage of a pleural effusion, chest trauma, management and complications of acute respiratory distress syndrome and tracheal intubation success or failure.