Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial.

OBJECTIVE: We examined the effect on survival of prone positioning as an early and continuous treatment in ARDS patients already treated with protective ventilation. DESIGN AND SETTING: Open randomized controlled trial in 17 medical-surgical ICUs. PATIENTS: Forty mechanically ventilated patients with early and refractory ARDS despite protective ventilation in the supine position. INTERVENTIONS: Patients were randomized to remain supine or be moved to early (within 48[Symbol: see text]h) and continuous (> or = 20 h/day) prone position until recovery or death. The trial was prematurely stopped due to a low patient recruitment rate. MEASUREMENTS AND RESULTS: Clinical characteristics, oxygenation, lung pressures, and hemodynamics were monitored. Need for sedation, complications, length of MV, ICU, and hospital stays, and outcome were recorded. PaO(2)/FIO(2) tended to be higher in prone than in supine patients after 6[Symbol: see text]h (202 +/-78 vs. 165+/-70 mmHg); this difference reached statistical significance on day 3 (234+/-85 vs. 159+/-78). Prone-related side effects were minimal and reversible. Sixty-day survival reached the targeted 15% absolute increase in prone patients (62% vs. 47%) but failed to reach significance due to the small sample. CONCLUSIONS: Our study adds data that reinforce the suggestion of a beneficial effect of early continuous prone positioning on survival in ARDS patients.

[Treatment of acute myocardial infarction by primary angioplasty on-site compared with treatment following interhospital transfer: short- and long-time clinical outcomes]. / Tratamiento del infarto agudo de miocardio con angioplastia primaria in situ frente a transferencia interhospitalaria para su realización: resultados clínicos a corto y largo plazo.

INTRODUCTION AND OBJECTIVES: Primary angioplasty is the treatment of first choice for patients with ST-segment elevation acute myocardial infarction. However, its use is limited as the majority of patients present at hospitals without a catheterization laboratory. The objective of this study was to determine short- and long-term outcomes of systematically implementing a primary angioplasty program at two hospitals, one of which did not have a catheterization laboratory. METHODS: This prospective observational study involved consecutive patients with acute myocardial infarction and an indication for reperfusion therapy who were admitted to the two participating hospitals (Hospital 1 had a catheterization laboratory, while Hospital 2 did not) between January 2000 and April 2001. Clinical follow-up was performed at 1, 6 and 12 months. RESULTS: The study included 222 patients: 158 in Hospital 1 and 64 in Hospital 2. The median (interquartile range) delays from door to angiography at Hospital 1 and Hospital 2 were 49.5 min (30.0-88.0 min) and 62.5 min (53.5-93.7 min), respectively (P=.001), and from symptoms to angiography, 162.5 min (105.0-247.5 min) and 187.5 min (131.2-288.7 min), respectively (P=.04). In-hospital and 1-year mortality rates were 12.2% and 15.3%, respectively, with no difference between the hospitals. The hospital of origin was not a determinant of either in-hospital mortality (odds ratio [OR]=1.42, 95% confidence interval [CI], 0.3-7.8) or 1-year mortality (HR=2.04, 95% CI, 0.74-5.61). CONCLUSIONS: Patients with ST-segment elevation acute myocardial infarction who require interhospital transfer for primary angioplasty have a similar clinical outcome to those who are admitted to a hospital at which the procedure is available, provided transfer is undertaken under optimal conditions (i.e., with a suitable means of transport and a short transfer time).

Tratamiento del infarto agudo de miocardio con angioplastia primaria in situ frente a transferencia interhospitalaria para su realización: resultados clínicos a corto y largo plazo / Treatment of acute myocardial infarction by primary angioplasty on-site compared with treatment following interhospital transfer: short- and long-time clinical outcomes

Introducción y objetivos. La angioplastia primaria es la estrategia de primera elección en el tratamiento de los pacientes con infarto con elevación del segmento ST. Sin embargo, su aplicación es reducida, ya que la mayoría de los pacientes acude a hospitales sin laboratorio de hemodinámica. Estudiamos los resultados clínicos a corto y largo plazo de un programa de aplicación sistemática de angioplastia primaria en 2 hospitales, uno de ellos sin laboratorio de hemodinámica. Métodos. Estudio prospectivo, observacional, de pacientes con infarto e indicación de reperfusión, ingresados de forma consecutiva en 2 hospitales entre enero de 2000 y abril de 2001 (hospital 1 con sala de hemodinámica y hospital 2 sin ésta). Se realizó seguimiento clínico al mes y a los 6 y 12 meses. Resultados. Se incluyó a 222 pacientes, 158 en el hospital 1 y 64 en el hospital 2. Las medianas (percentiles 25-75) de retraso en minutos en el hospital 1 frente al hospital 2 fueron: tiempo «puerta-angiografía» 49,5 (30-88) frente a 62,5 (53,5-93,7), p = 0,001; tiempo «síntomas-angiografía» 162,5 (105-247,5) frente a 187,5 (131,2-288,7), p = 0,04. La mortalidad hospitalaria y al año de seguimiento fue del 12,2 y el 15,3%, respectivamente, sin diferencias entre los hospitales. El hospital de procedencia no resultó un determinante de mortalidad hospitalaria (odds ratio = 1,42; intervalo de confianza [IC] del 95%, 0,3-7,8) ni al año de seguimiento (riesgo relativo = 2,04; IC del 95%, 0,74-5,61). Conclusiones. Los pacientes con infarto agudo de miocardio con elevación del segmento ST que precisan traslado interhospitalario para recibir angioplastia primaria tienen una evolución clínica similar a la de los pacientes que ingresan en hospitales con disponibilidad para esa técnica, si ésta se aplica en condiciones óptimas (medio de transporte adecuado y tiempo corto de traslado) (AU)

Introduction and objectives. Primary angioplasty is the treatment of first choice for patients with ST-segment elevation acute myocardial infarction. However, its use is limited as the majority of patients present at hospitals without a catheterization laboratory. The objective of this study was to determine short- and long-term outcomes of systematically implementing a primary angioplasty program at two hospitals, one of which did not have a catheterization laboratory. Methods. This prospective observational study involved consecutive patients with acute myocardial infarction and an indication for reperfusion therapy who were admitted to the two participating hospitals (Hospital 1 had a catheterization laboratory, while Hospital 2 did not) between January 2000 and April 2001. Clinical follow-up was performed at 1, 6 and 12 months. Results. The study included 222 patients: 158 in Hospital 1 and 64 in Hospital 2. The median (interquartile range) delays from door to angiography at Hospital 1 and Hospital 2 were 49.5 min (30.0-88.0 min) and 62.5 min (53.5-93.7 min), respectively (P=.001), and from symptoms to angiography, 162.5 min (105.0-247.5 min) and 187.5 min (131.2-288.7 min), respectively (P=.04). In-hospital and 1-year mortality rates were 12.2% and 15.3%, respectively, with no difference between the hospitals. The hospital of origin was not a determinant of either in-hospital mortality (odds ratio [OR]=1.42, 95% confidence interval [CI], 0.3-7.8) or 1-year mortality (HR=2.04, 95% CI, 0.74-5.61). Conclusions. Patients with ST-segment elevation acute myocardial infarction who require interhospital transfer for primary angioplasty have a similar clinical outcome to those who are admitted to a hospital at which the procedure is available, provided transfer is undertaken under optimal conditions (i.e., with a suitable means of transport and a short transfer time) (AU)