Predictors of mortality and neurological function in ICU patients recovering from cardiac arrest: A Spanish nationwide prospective cohort study.

OBJECTIVE: To identify predictors of mortality and neurological function in adult ICU patients recovering from cardiac arrest. DESIGN: A prospective cohort multicenter study was carried out. SETTING: Forty-six polyvalent ICUs. PATIENTS: A total of 595 patients recovering from out-of-hospital cardiac arrest (OHCA, n=285) or in-hospital cardiac arrest (IHCA, n=310). MAIN OUTCOME VARIABLES: Survival and recovery of neurological function. RESULTS: The mean cardiopulmonary resuscitation time was 18min (range 10-30). Moderate hypothermia was used in 197 patients, and 150 underwent percutaneous coronary intervention (PCI). Return of spontaneous circulation (ROSC) was achieved within 20min in 370 patients. Variables associated to mortality (ICU and in-hospital) were age (odds ratio [OR]=1.0, 95%CI 1.0-1.0 per year), non-cardiac origin of cardiac arrest (OR=2.16, 95%CI 1.38-3.38; P=0.001) and ROSC >20min (OR=3.07, 95%CI 1.97-4.78; P<0.001), whereas PCI and the presence of shockable rhythm exhibited a protective effect. Favorable neurological outcome was associated to shockable rhythm, ROSC <20min, and cardiac origin of arrest. Hypothermia did not affect survival or neurological outcome in the multivariate analysis. CONCLUSIONS: Age, non-cardiac origin of cardiac arrest and ROSC >20min were predictors of mortality. In contrast, cardiac arrest of cardiac origin, ROSC <20min, and defibrillable rhythms were associated to unfavorable neurological outcomes.

[Intensive care services resources in Spain]. / Recursos estructurales de los Servicios de Medicina Intensiva en España.

OBJECTIVES: To identify the resources related to the care of critically ill patients in Spain, which are available in the units dependent of the Services of Intensive Care Medicine (ICM) or other services/specialties, analyzing their distribution according to characteristics of the hospitals and by autonomous communities. DESIGN: Prospective observational study. SETTING: Spanish hospitals. PARTICIPANTS: Heads of the Services of ICM. MAIN OUTCOME VARIABLES: Number of units and beds for critically ill patients and functional dependence. RESULTS: The total number of registries obtained with at least one Service of ICM was 237, with a total of 100,198 hospital beds. Level iii (43.5%) and level ii (35%) hospitals predominated. A total of 73% were public hospitals and 55.3% were non-university centers. The total number of beds for adult critically ill patients, was 4,738 (10.3/100,000 inhabitants). The services of ICM registered had available 258 intensive are units (ICUs), with 3,363 beds, mainly polyvalent ICUs (81%) and 43 intermediate care units. The number of patients attended in the Services of ICM in 2008 was 174,904, with a percentage of occupation of 79.5% A total of 228 units attending critically ill patients, which are dependent of other services with 2,233 beds, 772 for pediatric patients or neonates, were registered. When these last specialized units are excluded, there was a marked predominance of postsurgical units followed by coronary and cardiac units. CONCLUSIONS: Seventy one per cent of beds available in the Critical Care Units in Spain are characterized by attending severe adult patients, are dependent of the services of ICM, and most of them are polyvalent.

[Recommendations of the Infectious Diseases Work Group (GTEI) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Infections in Critically Ill Patients Study Group (GEIPC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) for the diagnosis and treatment of influenza A/H1N1 in seriously ill adults admitted to the Intensive Care Unit]. / Recomendaciones del Grupo de Trabajo Enfermedades Infecciosas (GTEI) de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y el Grupo de Estudio de Infecciones en el Paciente Crítico (GEIPC) de la Sociedad Española de Enfermedades Infecciosas y Microbiología clínica (SEIMC) para el diagnóstico y tratamiento de la gripe A/H1N1 en pacientes adultos graves hospitalizados en las Unidades de Cuidados Intensivos.

The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150 x 10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48 h from the onset of symptoms), with a dose of 75 mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10 ml / kg and plateau pressure <35 mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.

Modelling home televisiting services using systems dynamic theory.

A quantitative model was developed to study the provision of a home televisiting service. Systems dynamic theory was used to describe the relationships between quality of care, accessibility and cost-effectiveness. Input information was gathered from the telemedicine literature, as well as from over 75 sessions of a televisiting service provided by the Severo Ochoa Hospital to 18 housebound patients from three different medical specialties. The model allowed the Severo Ochoa Hospital to estimate the equipment needed to support increased medical contacts for intensive cardiac and other patients.

Impact of a broadband interactive televisit/teleconsultation service for residential and working environments.

The availability of health care attention at the point of need is one of the key benefits of telemedicine. Home environment and working place are the two scenarios selected in this article to evaluate the impact of a televisit and teleconsultation service. 31 users from four different medical and patient groups participated in this study supported by European Commission ATTRACT project. The experiences, carried out in Madrid and Valencia Spanish sites, benefited from interactive broadband access networks to provide cost-effective telecare services. Key areas analyzed encompass systems usability, clinical outcomes, patients quality of care and infoethic issues. Services advantages were verified and compared both from patients and medical staff points of view. Main benefits pointed out refer to displacement reduction, better communication doctor/patient, provision of comfort or friendliness, more precise therapy follow-up and increases in patients sense of well being.

Patient satisfaction with a home televisiting service based on interactive television over a cable network.

Experience shows that high-quality audiovisual contact between remote health carers and patients facilitates a telemedicine service. However, the lack of broadband communication to the home usually prevents domestic televisiting. Deployment of cable networks in Spain has allowed the implementation of a home televisiting service designed for patients with chronic diseases. In a trial, 15 patients received televisits by three specialists and three nurses from the Severo Ochoa Hospital in Madrid. Five patients suffered from chronic pain, five were from the nephrology unit and five had been treated at the intensive-care unit after acute myocardial infarction. Each patient participated in three televisiting sessions, two provided by a specialist and the other by a nurse. The average length of a televisit was 12 min (range 5-21 min). The patients expressed their satisfaction with the service.

Using cable television networks for interactive home telemedicine services.

Most recent cable television network infrastructures can be used to deliver broadband interactive telemedicine services to the home. These facilities allow the provision of social and health services like medical televisiting for elderly, disabled and chronically ill patients; health tele-education; and teleconsultation on demand. Large numbers of patients could benefit from these services. There is also the increasing European tendency to offer customized home-care services. These applications are being developed and validated by a pilot project in Madrid as part of the ATTRACT project of the European Commission. The long-term aim is to develop broadband applications on a large scale to support low-cost interactive home telemedicine services for both patients and institutions.

Prospective, randomised, multicentre study of meropenem versus imipenem/cilastatin as empiric monotherapy in severe nosocomial infections.

The clinical and bacteriological efficacy and the tolerability of meropenem versus imipenem/cilastatin (both 1 g t.i.d.) in severe nosocomial infections were compared in a multicentre, randomised, nonblinded study. A total of 151 patients were recruited; 133 (66 meropenem, 67 imipenem/cilastatin) were clinically evaluable and 84 (42 meropenem, 42 imipenem/cilastatin) bacteriologically evaluable. Most clinically evaluable patients (90%) were in intensive care units, required mechanical ventilation (72%), and had received previous antibiotic therapy (62%). The mean (+/- SD) APACHE II score was 15.2 (+/- 6.6) in the meropenem group and 17.8 (+/- 6.8) in the imipenem/cilastatin group. The primary infections were nosocomial lower respiratory tract infections (56% of patients), intra-abdominal infections (15%), septicaemia (21%), skin/skin structure infections (5%), and complicated urinary tract infections (3%); 35% of the patients had two or more infections. There was no significant difference between the meropenem and imipenem/cilastatin groups in the rates of satisfactory clinical (weighted percentage 87% vs. 74%) or bacteriological (weighted percentage 79% vs. 71%) response. There was a slightly higher rate of clinical success with meropenem against primary or secondary lower respiratory tract infection (89% vs. 76%). Drug-related adverse events occurred in 17% and 15% of meropenem and imipenem/cilastatin patients, respectively. Meropenem (1 g t.i.d.) was as efficacious as the same dose of imipenem/cilastatin in this setting, and both drugs were well tolerated.