COVID-19 pneumonia: Perfusion abnormalities shown on subtraction CT angiography in apparently well-ventilated lungs. A prospective cohort study.

Purpose: To evaluate whether a subtraction CT angiography (sCTA) perfusion score may have prognostic value in patients with COVID-19 pneumonia. Method: This prospective cohort study included adult patients with RT-PCR-confirmed SARS-CoV-2 infection admitted to the ED and a sCTA performed within 24 h of admission between June and September 2020. Perfusion abnormalities (PA) in areas of apparently spared lung parenchyma on conventional CT images were assessed with sCTA perfusion score. Airspace disease extension was assessed with CT severity scores, which were then correlated with clinical outcomes (admission to ICU, requirement of IMV, and death). Inter-rater reliability (IRR) was assessed using Cohen's Kappa. Independent predictors of adverse outcomes were evaluated by multivariable logistic regression analyses using the Hosmer and Lemeshow's test. Results: 191 patients were included: 112 males (58%), median age of 60.8 years (SD ± 16.0). The IRR was very high (median Kappa statistic: 0.95). No association was found between perfusion CT scores and D-dimer levels (Kendall's Tau-B coefficient = 0.08, p = 0.16) or between PaO2/FiO2 ratios and D-dimer levels (Kendall's Tau-B coefficient = -0.10, p = 0.07). Multivariate analyses adjusting for parenchymal disease extension, vascular beaded appearance, pulmonary embolism, sex, and age showed that severe PA remained a significant predictor for ICU admission (AOR: 6.25, 95% CI 2.10-18.7, p = 0.001). The overall diagnostic capacity of this model was adequate (ROC AUC: 0.83; 95% CI 0.77-0.89). Conclusions: The assessment of pulmonary perfusion abnormalities in areas of apparently spared lung parenchyma on conventional CT images via sCTA perfusion scoring has prognostic value in COVID-19 pneumonia.

Early Predictors of Abdominal Hemorrhage Among Critically Ill Patients With Pancreatitis: A Prospective Cohort Study.

OBJECTIVE: To establish incidence, risk factors, and prognostic implications of abdominal hemorrhage (AH) among critically ill patients with acute pancreatitis (AP). METHODS: Prospective cohort study in 46 intensive care units aimed at describing the characteristics of critically ill patients with AP (Epidemiología de la Pancreatitis Aguda en Medicina Intensiva Study). Adult patients with AP and at least 1 organ failure were included. The presence of AH was established either by using computed tomography, magnetic resonance imaging, or by direct visualization during surgery. Statistical analyses were carried out using multivariate logistic regression. RESULTS: Three hundred seventy-four patients were studied. Most were men (62.6%), with a mean (standard deviation) age of 60.4 (15.6) years. Most episodes (56.4%) of AP were severe, and 28.9% died during their hospital stay. Thirty-eight patients (10.2%; 95% confidence interval, 7.3%-13.7%) developed AH. The odds of presenting AH was influenced by age, the underlying cause of pancreatitis, and the presence of shock or respiratory failure on admission. CONCLUSIONS: Abdominal hemorrhages were common among critically ill patients with pancreatitis. These early predictors may be of use in detecting patients at risk of developing them.

Implementing a Multicomponent Intervention to Prevent Delirium Among Critically Ill Patients.

BACKGROUND: Delirium is common among the critically ill. Nonpharmacologic interventions are reportedly effective in reducing incident delirium, but limited data specific to this population exist. OBJECTIVES: To assess the efficacy and describe the implementation strategy of a multicomponent intervention to prevent delirium in an intensive care unit. METHODS: A before-and-after study was conducted in an intensive care unit between May 2014 through August 2015. Adult participants were enrolled consecutively, excluding only those who refused to participate. Tailored interventions took available evidence into consideration. Components included early mobilization, physical therapy, reorientation, cognitive stimulation, drug reviews, environmental stimulation, avoidance of sensory deprivation, pain control, restraint use avoidance, and family participation. Incident delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Multivariate logistic regression was used to control for confounders. RESULTS: The study included 227 patients (54.7% male; mean [SD] age, 63.3 [18.3] years). Our strategy significantly reduced delirium (from 38% to 24%; relative risk, 0.62; 95% CI, 0.40-0.94; P = .02), an association that remained significant after adjusting for confounders. Adherence rates were more than 85% in all intervention domains (except daily reorientation) that were overseen by health care providers. CONCLUSIONS: The strategy was successful in reducing delirium. Self-removals of invasive implements decreased, an observation that has not been previously described. No difference in mortality rate was seen, as has been reported in other studies. Early participation of the whole team, shared leadership, and the provision of concrete tasks were key to the success of this multicomponent intervention.

Predicting the need of tracheostomy amongst patients admitted to an intensive care unit: a multivariate model.

BACKGROUND: Patients requiring prolonged invasive mechanical ventilation are prone to complications, such as infections, tracheal stenosis and death. It has been proposed that early tracheostomy could have a role in preventing these outcomes, but the proper identification of patients at risk can be difficult. PURPOSE: The aim of this study was to develop a multivariate model that allows the early detection of patients that will require prolonged ventilatory support. PATIENTS AND METHODS: A retrospective cohort study was undertaken in the intensive care unit of the Hospital Naval Almirante Nef, Chile, between June 2011 and June 2012. The charts of all intubated patients were reviewed in search for early predictors of prolonged intubation (>7 days). Multivariate logistic regression analysis was used to detect statistically significant associations and to assess potential confounders. RESULTS: A total of 349 patients were admitted to the intensive care unit during the study period and 142 (40.7%) required invasive mechanical ventilation. Most of them were male (60.5%), with a mean age of 65.8 ± 16.7 years. Thirty-five patients (24%) required to be ventilated for 7 days or more, and 16 (46%) were tracheostomized for this reason. The regression model showed that older age (p=0.026), a Pa/Fi ratio of less than 200 (p=0.046), and the presence of chronic pulmonary disease (p=0.035) or hypernatremia (p=0.012) on intubation day were significantly associated with the requirement of prolonged intubation. DISCUSSION: Invasive mechanical ventilation is a common reason for admittance to the ICU. The abovementioned predictors can be of assistance when selecting patients that could benefit from early tracheostomies, and are in agreement with earlier reports. Although the model's discriminating capacity was good, it is necessary to formally validate it before recommending its widespread use.

Terapia de transfusion en trauma, ¿hora de cambiar nuestro enfoque? / Transfusion therapy in trauma: time to change our approach?

En la actualidad, el trauma constituye, por su alta frecuencia de presentación un problema no solo en su manejo sino que también de salud pública. La mejoría en los diferentes sistemas de rescate permite la recepción de pacientes más graves cuyo requerimiento de transfusiones es mayor y si bien son en grupo minoritario dentro del total de trauma aportan con una alta mortalidad especialmente en las primeras horas siendo la hemorragia y la coagulopatía la causa de ésta. Los recientes conflictos bélicos han planteado un cambio en el manejo transfusional de estos pacientes orientando hacia prácticas que incrementan la relación de GR, plasma fresco congelado (PFC)y plaquetas aportadas, tratando de simular el aporte de sangre total en las primeras horas de ocurrido el accidente.

Trauma is a very important public health problem and also a practice management. The aim of prehospital care of bleeding patient is to deliver the patient to a facility for definitive care. Trauma associated bleeding and coagulopaty is the principal cause of preventible death. Recent military experience suggest that FFP and platelets should be given early and more often to injured patient.

Treatment of idiopathic retroperitoneal fibrosis with colchicine and steroids: a case series.

BACKGROUND: Idiopathic retroperitoneal fibrosis (IRPF) is an uncommon, but increasingly recognized, disease. Autoimmune mechanisms probably participate in its pathogenesis. Patients have been treated with high-dose steroids and sometimes immunosuppressive drugs, resulting in toxicity risk during prolonged treatments; thus, it would be wise to look for safer drugs. Colchicine has antifibrotic, anti-inflammatory, and immunosuppressive effects. Hence, it is a potential therapeutic resource. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: 7 consecutives patients with IRPF diagnosed since 1993 at a navy hospital were prescribed colchicine plus prednisone or deflazacort. After reaching a clinical response, the steroid dose was tapered, maintaining daily colchicine therapy. OUTCOMES & MEASUREMENTS: Symptomatic improvement was defined as time to relief of symptoms; clinical improvement, time to normalization of inflammatory parameters with symptomatic improvement; radiological changes, percentage of decrease in retroperitoneal mass; recurrence, as the need to increase steroid dose or add immunosuppressors because of reactivation of inflammation; and treatment failure, as persistence of signs of active inflammation and/or decrease in retroperitoneal mass less than 50% and/or deterioration in kidney function at the last visit. RESULTS: At month 3 of treatment, all patients had symptomatic improvement and 67% had clinical improvement. Between 8 and 12 months, 67% of patients had a decrease in retroperitoneal mass greater than 50%. No recurrence or treatment failure was observed during follow-up (mean, 72.5 months). At the last visit, all patients had a significant decrease in retroperitoneal mass (mean, 79.8% +/- 19.7%). One patient died of septic shock on day 21 of treatment. LIMITATIONS: This series did not have a control group. CONCLUSIONS: Colchicine in association with a low induction dose of steroids (<0.5 mg/kg/d) produced remission rates in patients with IRPF similar to those for regimens using greater steroid doses alone or in combination with immunosuppressive drugs. In addition, colchicine may have contributed to recurrence prevention.

Isquemia mesentérica crónica: caso clínico / Chronic mesenteric ischemia: a clinical case

Se presenta un caso clínico de isquemia mesentérica crónica, catalogado como "Angina Intestinal" típica, diagnosticado y tratado en el Hospital Naval de Valparaíso. Se discute sobre la forma de presentación clínica de estos pacientes, analizando en forma breve los principales síntomas que caracterizan esta enfermedad y se comentan aspectos importantes a considerar en la reparación quirúrgica. Consideramos como excelente el resultado inicial del tratamiento en este caso, ya que nuestra paciente se encuentra libre de síntomas, a los diez meses de operación

Cierre de colostomías temporales: experiencia de 128 casos / Closure of temporal colostomies: 128 cases experience

Se analiza la evolución de 128 pacientes sometidos al cierre de una colostomía temporal. La serie está constituída por 86 hombres y 42 mujeres, cuyas edades fluctuaron entre 11 y 85 años con un promedio de 40,6. La técnica utilizada fue uniforme en todos los pacientes: monoplana e interperitoneal para las colostomías en asa y monoplana a cara anterior del muñón rectal en las colostomías de Hartmann. La colostomía más frecuente fue la transversa (46,8%) seguida por la colostomía de Hartmann (28,9%). La morbilidad global fue de 17,2%: infección de la herida operatoria en 12,5% (16/128), fístula anastomótica en 3,1% (4/128) y obstrucción en 1,6% (2/128). Hubo mayor incidencia de infección en los cierres de las colostomías transversas y colostomías de Hartmann. Las fístulas y la obstrucción se presentaron en pacientes operados antes de 8 semanas de realizada la colostomía. La mortalidad fue de 0,8% (1 paciente)