ABSTRACT
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
Subject(s)
Female , Humans , Male , Middle Aged , Hydrologic Balance/analysis , Hydrologic Balance/methods , Hydrologic Balance/prevention & control , Hypoxia/complications , Extravascular Lung Water , Extravascular Lung Water/physiology , Extravascular Lung Water , Critical Care/methods , Retrospective Studies , Clinical Protocols/standards , Lung Injury/complications , Lung Injury/physiopathology , Lung Injury/therapy , Intensive Care Units/standards , Intensive Care Units/trendsABSTRACT
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.
Subject(s)
Acute Lung Injury/therapy , Extravascular Lung Water , Hypoxia/physiopathology , Pulmonary Edema/prevention & control , Respiratory Distress Syndrome/therapy , Water-Electrolyte Balance , Acute Lung Injury/complications , Acute Lung Injury/physiopathology , Adult , Aged , Clinical Protocols , Extravascular Lung Water/physiology , Female , Fluid Therapy/methods , Hemodynamics , Humans , Hypoxia/etiology , Hypoxia/therapy , Male , Middle Aged , Monitoring, Physiologic , Pulmonary Edema/etiology , Pulmonary Edema/physiopathology , Pulmonary Gas Exchange , Pulmonary Wedge Pressure , Respiration, Artificial , Respiratory Distress Syndrome/complications , Respiratory Distress Syndrome/physiopathology , Sepsis/complications , ThermodilutionABSTRACT
Existen diferencias profundas en la formación, desempeño profesional y manejo de las unidades de cuidados intensivos entre Estados Unidos y los países de la Unión Europea en general y de España en particular. Algunos de los aspectos sobresalientes de la medicina intensiva en Estados Unidos son el modelo de acceso y las evaluaciones permanentes de la residencia, la formación en etapas escalonadas con empleabilidad en cada una de ellas, las competencias a alcanzar en cada etapa, la inclusión de la investigación como valor central, la actividad clínica que abarca no solo las unidades de cuidados intensivos, sino también las salas de hospitalización y las consultas ambulatorias. Los perfiles de las unidades de cuidados intensivos y el papel de los médicos intensivistas son flexibles y se adaptan a las características de los hospitales en los que se encuentran (AU)
There exist profound differences in the training and professional duties of intensive care physicians and the way intensive care units are managed between the United States and Europe and particularly Spain. Some of the remarkable characteristics of intensive care medicine in the united states include the application process for residency, continuing evaluation during training, phased training with employability at every level, competency based training, scientific research as a core value during training and medical practice, and clinical activity reaching beyond the intensive care unit to include regular hospital wards and ambulatory clinics. The characteristics of intensive care units and the role of intensive care physicians are flexible and change according to the needs of the hospitals where they are located (AU)
Subject(s)
Humans , Intensive Care Units , Specialization , Education, Medical/trends , Critical Care/methods , Internship and Residency/organization & administration , United States , Critical CareABSTRACT
There exist profound differences in the training and professional duties of intensive care physicians and the way intensive care units are managed between the United States and Europe and particularly Spain. Some of the remarkable characteristics of intensive care medicine in the united states include the application process for residency, continuing evaluation during training, phased training with employability at every level, competency based training, scientific research as a core value during training and medical practice, and clinical activity reaching beyond the intensive care unit to include regular hospital wards and ambulatory clinics. The characteristics of intensive care units and the role of intensive care physicians are flexible and change according to the needs of the hospitals where they are located.
