Lung ultrasound score predicts outcomes in patients with acute respiratory failure secondary to COVID-19 treated with non-invasive respiratory support: a prospective cohort study.

BACKGROUND: Lung ultrasound has demonstrated its usefulness in several respiratory diseases management. One derived score, the Lung Ultrasound (LUS) score, is considered a good outcome predictor in patients with Acute Respiratory Failure (ARF). Nevertheless, it has not been tested in patients undergoing non-invasive respiratory support (NIRS). Taking this into account, the aim of this study is to evaluate LUS score as a predictor of 90-day mortality, ETI (Endotracheal intubation) and HFNC (High Flow Nasal Cannula) failure in patients with ARF due to COVID-19 admitted to a Respiratory Intermediate Care Unit (RICU) for NIRS management. RESULTS: One hundred one patients were admitted to the RICU during the study period. Among these 76% were males and the median age was 55 (45-64) years. Initial ARF management started with HFNC, the next step was the use of Continuous Positive Airway Pressure (CPAP) devices and the last intervention was ETI and Intensive Care Unit (ICU) admission. Of the total study population, CPAP was required in 40%, ETI in 26%, while 15% died. By means of a ROC analysis, a LUS ≥ 25 points was identified as the cut-off point for mortality(AUC 0.81, OR 1.40, 95% CI 1.14 to 1.71; p < 0.001), ETI (AUC 0.83, OR 1.43, 95% CI 1.20 to 1.70; p < 0.001) and HFNC failure (AUC 0.75, OR 1.25, 95% CI 1.12 to 1.41; p < 0.001). Kaplan-Meier survival curves also identified LUS ≥ 25 as a predictor of 90-days mortality (HR 4.16, 95% CI 1.27-13.6) and 30 days ETI as well. CONCLUSION: In our study, a ≥ 25 point cut-off of the Lung Ultrasound Score was identified as a good outcome prediction factor for 90-days mortality, ETI and HFNC failure in a COVID-19 ARF patients cohort treated in a RICU. Considering that LUS score is easy to calculate, a multicenter study to confirm our findings should be performed.

Ultrasound-guided cerebral resuscitation in patients with severe traumatic brain Injury.

Traumatic brain injury (TBI) is a worldwide public health concern given its significant morbidity and mortality, years of potential life lost, reduced quality of life and elevated healthcare costs. The primary injury occurs at the moment of impact, but secondary injuries might develop as a result of brain hemodynamic abnormalities, hypoxia, and hypotension. The cerebral edema and hemorrhage of the injured tissues causes a decrease in cerebral perfusion pressure (CPP), which leads to higher risk of cerebral ischemia, herniation and death. In this setting, our role as physicians is to minimize damage by the optimization of the CPP and therefore to reduce mortality and improve neurological outcomes. Performing a transcranial doppler ultrasound (TCD) allows to estimate cerebral blood flow velocities and identify states of low flow and high resistance. We propose to include TCD as an initial assessment and further monitoring tool for resuscitation guidance in patients with severe TBI. We present an Ultrasound-Guided Cardio-cerebral Resuscitation (UGCeR) protocol in Patients with Severe TBI.

Combined Noninvasive Respiratory Support Therapies to Treat COVID-19.

BACKGROUND: The roles of high-flow nasal cannula (HFNC) and CPAP in coronavirus disease 2019 (COVID-19) are controversial. The objective of the study was to evaluate the impact of the application of a noninvasive respiratory support algorithm on clinical outcomes in subjects with COVID-19 and with acute respiratory failure. METHODS: We performed a single-center prospective observational study of subjects with respiratory failure from COVID-19 managed with HFNC and with CPAP plus HFNC (combined therapy). The main outcome was the intubation rate, which defined failure of therapy. We also analyzed the role of the ROX index ([[Formula: see text]/[Formula: see text]]/breathing frequency) to predict the need for intubation. RESULTS: From June to December 2020, 113 subjects with COVID-19 respiratory failure were admitted to our respiratory intermediate care unit. HFNC was applied in 65 subjects (57.52%) and combined therapy in 48 subjects (42.47%). A total of 83 subjects (73.45%) were successfully treated with noninvasive respiratory support. The intubation rate was 26.54%, and the overall mortality rate was 14.15%. The mortality rate in subjects who were intubated was 55.2%. An ROX index of 6.28 at 12 h predicted noninvasive respiratory support failure, with 97.6% sensitivity and 51.8% specificity. CONCLUSIONS: Data from our cohort managed in a respiratory intermediate care unit showed that combined noninvasive respiratory support was feasible, with favorable outcomes. Further prospective studies are required.

Resultados preliminares de una unidad de soporte ventilatorio no invasivo en SARS-COV-2 / Preliminary results of a non-invasive ventilatory support unit in SARS-COVID-2

Resumen La utilización de tratamientos de soporte respiratorio no invasivos en la pandemia por COVID-19, es motivo de controversias. El objetivo de este trabajo observacional, fue mostrar la experiencia del primer mes desde la creación de la Unidad de Soporte Ventilatorio no Invasivo (USoVNI) en el Hospital Fernández. Se describe la creación de la unidad, relación profesional de atención-paciente, tipo de habitación, equipo de protección personal modificado, equipamiento de diagnóstico, monitoreo y soporte ventilatorio para tratamiento, criterios de inclusión y algoritmo de tratamiento. Ingresaron 40 pacientes, 25 (63%) derivados de Clínica Médica, 10 (25%) de Emergentología y 5 (13%) de guardia externa. Al ingreso, se calcularon los escores National Early Warning Score, Acute Physiology and Chronic Health Disease Classification System II y Sequential Organ Failure Assessment, con medianas de 12, 8, y 2 puntos, respectivamente. El escore Lung Ultrasonography Score se tomó para cuantificar el compromiso pulmonar ecográficamente. Todos los pacientes ingresaron con máscara con reservorio, y fue estimada una fracción inspirada de O de 80% para el cálculo de la razón presión arterial de O / fracción inspirada de O (Pa/FiO ) de ingreso. El tiempo transcurrido desde el inicio de síntomas hasta el ingreso a la unidad tuvo una mediana de 13 días. El desarrollo de la USoVNI permitió que una gran proporción no fueran trasladados a la Unidad de Terapia Intensiva y podría ser beneficioso para preservar su capacidad. Nuestros resultados sugieren que estas unidades resultarían adecuadas para el tratamiento de la insuficiencia respiratoria aguda grave por COVID-19.

Abstract The use of non-invasive respiratory support in the context of the COVID-19 pandemic is controversial. The aim of this observational study was to show the experience of the first month since the creation of a Non-invasive Ventilatory Support Unit (NIVSU) at Hospital Fernández. We describe the creation of the NIVSU, the health professional-patient ratio, the type of room, the modified personal protection equipment; diagnostic, monitoring and ventilatory support equipment for treatment, as well as the inclusion criteria and the treatment algorithm. Twenty five (63%) of patients were referred from the Internal Medicine Ward, 10 (25%)) from Shock Room, and 5 (13%) from Emergency Ward. National Early Warning Score, Acute Physiology and Chronic Health Disease Classification System II and Sequential Organ Failure Assessment, were calculated on admission, with a median of 12, 8, and 2 points, respectively. The Lung Ultrasonography Score was taken to quantify lung ultrasound findings. All patients were admitted with a reservoir mask, 80% inspired O fraction was estimated for the calculation of arterial O pressure/ inspired O fraction ratio (Pa/FiO ) at admission. The median of time elapsed from the onset of symptoms referred by the patient to UNIT admission was 13 days. The development of NIVSU prevented a large proportion of patients from being transferred to Intensive Care Unit (ICU) and it could be beneficial in preserving ICUs capacity. These early results suggest that non-invasive treatment may be beneficial for the treatment of severe acute respiratory failure by COVID-19.

[Preliminary results of a non-invasive ventilatory support unit in SARS-COVID-2]. / Resultados preliminares de una unidad de soporte ventilatorio no invasivo en SARS-COV-2.

The use of non-invasive respiratory support in the context of the COVID-19 pandemic is controversial. The aim of this observational study was to show the experience of the first month since the creation of a Non-invasive Ventilatory Support Unit (NIVSU) at Hospital Fernández. We describe the creation of the NIVSU, the health professional-patient ratio, the type of room, the modified personal protection equipment; diagnostic, monitoring and ventilatory support equipment for treatment, as well as the inclusion criteria and the treatment algorithm. Twenty five (63%) of patients were referred from the Internal Medicine Ward, 10 (25%)) from Shock Room, and 5 (13%) from Emergency Ward. National Early Warning Score, Acute Physiology and Chronic Health Disease Classification System II and Sequential Organ Failure Assessment, were calculated on admission, with a median of 12, 8, and 2 points, respectively. The Lung Ultrasonography Score was taken to quantify lung ultrasound findings. All patients were admitted with a reservoir mask, 80% inspired O2 fraction was estimated for the calculation of arterial O2 pressure/ inspired O2 fraction ratio (Pa/FiO2) at admission. The median of time elapsed from the onset of symptoms referred by the patient to UNIT admission was 13 days. The development of NIVSU prevented a large proportion of patients from being transferred to Intensive Care Unit (ICU) and it could be beneficial in preserving ICUs capacity. These early results suggest that non-invasive treatment may be beneficial for the treatment of severe acute respiratory failure by COVID-19.

La utilización de tratamientos de soporte respiratorio no invasivos en la pandemia por COVID-19, es motivo de controversias. El objetivo de este trabajo observacional, fue mostrar la experiencia del primer mes desde la creación de la Unidad de Soporte Ventilatorio no Invasivo (USoVNI) en el Hospital Fernández. Se describe la creación de la unidad, relación profesional de atención-paciente, tipo de habitación, equipo de protección personal modificado, equipamiento de diagnóstico, monitoreo y soporte ventilatorio para tratamiento, criterios de inclusión y algoritmo de tratamiento. Ingresaron 4 0 pacientes, 25 (63%) derivados de Clínica Médica, 10 (25%) de Emergentología y 5 (13%) de guardia externa. Al ingreso, se calcularon los escores National Early Warning Score, Acute Physiology and Chronic Health Disease Classification System II y Sequential Organ Failure Assessment, con medianas de 12, 8, y 2 puntos, respectivamente. El escore Lung Ultrasonography Score se tomó para cuantificar el compromiso pulmonar ecográficamente. Todos los pacientes ingresaron con máscara con reservorio, y fue estimada una fracción inspirada de O2 de 80% para el cálculo de la razón presión arterial de O2/ fracción inspirada de O2 (Pa/FiO2) de ingreso. El tiempo transcurrido desde el inicio de síntomas hasta el ingreso a la unidad tuvo una mediana de 13 días. El desarrollo de la USoVNI permitió que una gran proporción no fueran trasladados a la Unidad de Terapia Intensiva y podría ser beneficioso para preservar su capacidad. Nuestros resultados sugieren que estas unidades resultarían adecuadas para el tratamiento de la insuficiencia respiratoria aguda grave por COVID-19.

A Case Report on the Use of Pharmacological Intervention in the Treatment of Diffuse Axonal Injury From Road Traffic Accidents.

We report a case of traumatic brain injury treated with Cerebrolysin, a neurorecovery stimulating agent. Our therapeutic approach was based on the pathophysiology of traumatic brain injury and, in particular, of diffuse axonal injury. The patient registered marked improvement in mood and cognitive performance, indicating the effectiveness of multimodal and multidisciplinary interventions after traumatic brain injury.

Delirium in a Latin American intensive care unit. A prospective cohort study of mechanically ventilated patients. / Delirium em uma unidade de terapia intensiva latino-americana. Estudo prospectivo em coorte em pacientes em ventilação mecânica.

OBJECTIVE: To establish the prevalence of delirium in a general intensive care unit and to identify associated factors, clinical expression and the influence on outcomes. METHODS: This was a prospective cohort study in a medical surgical intensive care unit. The Richmond Agitation-Sedation Scale and Confusion Assessment Method for the Intensive Care Unit were used daily to identify delirium in mechanically ventilated patients. RESULTS: In this series, delirium prevalence was 80% (N = 184 delirious patients out of 230 patients). The number of patients according to delirium psychomotor subtypes was as follows: 11 hyperactive patients (6%), 9 hypoactive patients (5%) and 160 mixed patients (89%). Multiple logistic regression modeling using delirium as the dependent outcome variable (to study the risk factors for delirium) revealed that age > 65 years, history of alcohol consumption, and number of mechanical ventilation days were independent variables associated with the development of delirium. The multiple logistic regression model using hospital mortality as the dependent outcome variable (to study the risk factors for death) showed that severity of illness, according to the Acute Physiology and Chronic Health Evaluation II, mechanical ventilation for more than 7 days, and sedation days were all independent predictors for excess hospital mortality. CONCLUSION: This Latin American prospective cohort investigation confirmed specific factors important for the development of delirium and the outcome of death among general intensive care unit patients. In both analyses, we found that the duration of mechanical ventilation was a predictor of untoward outcomes.

OBJETIVO: Estabelecer a prevalência do delirium em uma unidade de terapia intensiva geral e identificar os fatores associados, sua expressão clínica e sua influência no desfecho. MÉTODOS: Trata-se de um estudo prospectivo de coorte em uma unidade de terapia intensiva clínico-cirúrgica. Avaliamos os pacientes diariamente, com a Richmond Agitation-Sedation Scale e a Confusion Assessment Method for the Intensive Care Unit, com o objetivo de identificar delirium nos pacientes mecanicamente ventilados. RESULTADOS: Nesta série de casos, a prevalência de delirium foi de 184 pacientes com delirium em um total de 230 pacientes. O subtipo de delirium psicomotor foi hiperativo em 11 pacientes (6%), hipoativo em 9 (5%) e misto em 160 (89%). Uma modelagem de regressão logística múltipla, com delirium como a variável de desfecho dependente (para avaliar os fatores de risco para delirium), revelou que idade acima de 65 anos, histórico de consumo de álcool e dias em uso de ventilação mecânica foram variáveis que se associaram independentemente com o desenvolvimento de delirium. Um modelo de regressão logística múltipla, que utilizou mortalidade hospitalar como variável de desfecho dependente (para estudar os fatores de risco para óbito), mostrou que o índice de severidade da doença, como o aferido segundo o escore Acute Physiology and Chronic Health Evaluation II, o uso de ventilação mecânica por mais de 7 dias e o número de dias de sedação foram as dependentes preditoras de mortalidade hospitalar mais elevada. CONCLUSÃO: Este estudo latino-americano de coorte confirmou os fatores específicos importantes para delirium e o desfecho óbito entre pacientes admitidos a uma unidade de terapia intensiva geral. Em ambas as análises, identificamos que a duração da ventilação mecânica é um preditor de desfechos desfavoráveis.

Delirium em uma unidade de terapia intensiva latino-americana. Estudo prospectivo em coorte em pacientes em ventilação mecânica / Delirium in a Latin American intensive care unit. A prospective cohort study of mechanically ventilated patients

RESUMO Objetivo: Estabelecer a prevalência do delirium em uma unidade de terapia intensiva geral e identificar os fatores associados, sua expressão clínica e sua influência no desfecho. Métodos: Trata-se de um estudo prospectivo de coorte em uma unidade de terapia intensiva clínico-cirúrgica. Avaliamos os pacientes diariamente, com a Richmond Agitation-Sedation Scale e a Confusion Assessment Method for the Intensive Care Unit, com o objetivo de identificar delirium nos pacientes mecanicamente ventilados. Resultados: Nesta série de casos, a prevalência de delirium foi de 184 pacientes com delirium em um total de 230 pacientes. O subtipo de delirium psicomotor foi hiperativo em 11 pacientes (6%), hipoativo em 9 (5%) e misto em 160 (89%). Uma modelagem de regressão logística múltipla, com delirium como a variável de desfecho dependente (para avaliar os fatores de risco para delirium), revelou que idade acima de 65 anos, histórico de consumo de álcool e dias em uso de ventilação mecânica foram variáveis que se associaram independentemente com o desenvolvimento de delirium. Um modelo de regressão logística múltipla, que utilizou mortalidade hospitalar como variável de desfecho dependente (para estudar os fatores de risco para óbito), mostrou que o índice de severidade da doença, como o aferido segundo o escore Acute Physiology and Chronic Health Evaluation II, o uso de ventilação mecânica por mais de 7 dias e o número de dias de sedação foram as dependentes preditoras de mortalidade hospitalar mais elevada. Conclusão: Este estudo latino-americano de coorte confirmou os fatores específicos importantes para delirium e o desfecho óbito entre pacientes admitidos a uma unidade de terapia intensiva geral. Em ambas as análises, identificamos que a duração da ventilação mecânica é um preditor de desfechos desfavoráveis.

ABSTRACT Objective: To establish the prevalence of delirium in a general intensive care unit and to identify associated factors, clinical expression and the influence on outcomes. Methods: This was a prospective cohort study in a medical surgical intensive care unit. The Richmond Agitation-Sedation Scale and Confusion Assessment Method for the Intensive Care Unit were used daily to identify delirium in mechanically ventilated patients. Results: In this series, delirium prevalence was 80% (N = 184 delirious patients out of 230 patients). The number of patients according to delirium psychomotor subtypes was as follows: 11 hyperactive patients (6%), 9 hypoactive patients (5%) and 160 mixed patients (89%). Multiple logistic regression modeling using delirium as the dependent outcome variable (to study the risk factors for delirium) revealed that age > 65 years, history of alcohol consumption, and number of mechanical ventilation days were independent variables associated with the development of delirium. The multiple logistic regression model using hospital mortality as the dependent outcome variable (to study the risk factors for death) showed that severity of illness, according to the Acute Physiology and Chronic Health Evaluation II, mechanical ventilation for more than 7 days, and sedation days were all independent predictors for excess hospital mortality. Conclusion: This Latin American prospective cohort investigation confirmed specific factors important for the development of delirium and the outcome of death among general intensive care unit patients. In both analyses, we found that the duration of mechanical ventilation was a predictor of untoward outcomes.

Dignificando el Final de la Vida en Cuidados Intensivos / Dignifying the End of Life in the Intensive Care Unit

Con frecuencia, cuando una persona se enferma, comienza un complicado proceso de consultas médicas, utilización de sofisticados medios auxiliares de diagnóstico, e instauración de tratamientos cada vez más complejos y costosos. Cuando, en vez de curar la enfermedad progresa; el enfermo se ve abrumado por la aplicación de nuevas exploraciones altamente tecnificadas que persiguen alcanzar un diagnóstico más preciso de la enfermedad a fin de instaurar medidas terapéuticas más agresivas. Como es de esperar, en muchos casos la enfermedad sigue su curso y llega un momento en el que tanto el paciente como sus allegados y el equipo médico se preguntan hasta qué punto es razonable continuar. Esta encrucijada es el punto de decisión de aceptar el final de la vida como evento natural. Pero en muchos casos se percibe como un fracaso, y no como la historia natural de los procesos graves.

Frequently, when a person falls ill, a complicated process of medical visits, use of sophisticated auxiliary means for diagnosis, and the establishment of treatments that are becoming more and more complex and expensive starts. When, instead of the patient's getting cured, the illness advances, the patient becomes overwhelmed due to the new and highly developed explorations that pursue a more precise diagnosis of the illness in order to establish more aggressive therapeutic measures. As it is expected, the illness, in many cases, continues advancing and reaches a moment in which both the patient and their close relatives, as well as the medical team, wonder until when it is still reasonable to continue with the treatments. This crossroads is the point of decision to accept death as a natural event. Most of the times, nevertheless, death is perceived as a failure, not as the natural story of serious processes.

Recomendaciones para el uso de anticonvulsivantes en el paciente con patologías neurológicas críticas más comunes. Revisión / Recommendations for the use of anticonvulsants in the patient with more common critical neurological pathologies. Review

INTRODUCCIÓN: El uso de medicación anticomicial en el pacienteneurocrítico plantea múltiples debates en el equipo médico.Las actuales recomendaciones sobre el uso de medicación anticomicial en pacientes neurocríticos dejan vacíos con relación a su uso en situaciones particulares en este grupo de patologías.MATERIAL Y MÉTODOS: Se realizó revisión bibliográfica en bases de datos como COCHRANE y NCBI-PUBMED con términos MeSH: intracranial Haemorrhage, Subaracnoideal Haemorrhage, Stroke, Traumatic Brain Injury, seizures, antiepileptics drugs. Se incluyeron las guías de la American Heart Association (AHA), American Association Of Neurology (AAN), American Association of neurological Surgeons (AANS), Brain Trauma Foundation, centrando en el inicio de profilaxis de anticomicial al ingreso en la Unidad de Cuidados Intensivos.Las recomendaciones se realizaron utilizando el sistema de clasificación de recomendación y grados de evidencia propuesto por las guías de la AHA.RESULTADOS: Pocas recomendaciones son con evidencias de alto grado, la mayoría son basadas en reportes retrospectivos y recomendación de expertos. CONCLUSIONES: La literatura actual disponible subraya la necesidad de mayor investigación en el tema, por lo que se da lugar a debates al momento de tomar la decisión del uso de dicha medicación, incluyendo los interrogantes habituales sobre la aparición de efectos adversos y la evaluación de su relación costo ­ efectividad

INTRODUCTION: The use of anticonvulsant medication on the neurocritic patient raises multiple debates in the medical team. The present recommendations about the use of anticonvulsant medication on the neurocritic patient leave empty spaces in relation to their use in particular situations in this group of pathologies. MATERIAL AND METHODS: A bibliographical revision was done in databases such as COCHRANE and NCBI-PUBMED with MeSH terminology: intracranial haemorrhage, subaracnoideal haemorrhage, stroke, traumatic brain injury, seizures, and antiepileptic drugs. In order to focus on the beginning of anticonvulsant prophylaxis when entering the ICU, guides from several associations were included: American Heart Association (AHA), American Association of Neurology (AAN), American Association of Neurological Surgeons (AANS) and Brain Trauma Foundation. The recommendations were made using the classification system of recommendation and degrees of evidence proposed by the guides of the AHA. RESULTS: Few recommendations are given with a high degree; most of them are based on retrospective reports and the recommendation of experts. CONCLUSIONS: The present available literature highlights the need for more investigation on the topic. Because of this, more debates take place when making a decision about the use of said medication, including the habitual questioning about adverse effects and the evaluation of its cost - effectiveness

[Changes in cerebral hemodynamics in chronic users of "PACO" and cocaine: case-control study]. / Cambios en la hemodinamia cerebral en consumidores crónicos de paco y cocaína: estudio de casos y controles.

OBJECTIVE: To assess if there are changes in brain hemodynamics evaluated by means of transcranial doppler's flow velocity, pulsatile index and cerebral perfusion pressure, between cocaine chronic abusers and healthy volunteers. METHOD: Prospective, case and control, observational study. Sex, age, user history, vital signs and transcranial doppler findings.Statistical analysis was performed by means of normality test, Wilcoxon's test for non parametric samples and T Student test. RESULTS: Fifty-three abusers and 35 healthy volunteers were studied. Statistical differences were found for a diminish in age(p=0.008) and cerebral perfusion pressure in all cerebral arteries (p

Cambios en la hemodinamia cerebral en consumidores crónicos de paco y cocaína: estudio de casos y controles. / [Changes in cerebral hemodynamics in chronic users of "PACO" and cocaine: case-control study].

OBJECTIVE: To assess if there are changes in brain hemodynamics evaluated by means of transcranial dopplers flow velocity, pulsatile index and cerebral perfusion pressure, between cocaine chronic abusers and healthy volunteers. METHOD: Prospective, case and control, observational study. Sex, age, user history, vital signs and transcranial doppler findings.Statistical analysis was performed by means of normality test, Wilcoxons test for non parametric samples and T Student test. RESULTS: Fifty-three abusers and 35 healthy volunteers were studied. Statistical differences were found for a diminish in age(p=0.008) and cerebral perfusion pressure in all cerebral arteries (p

Cambios en la hemodinamia cerebral en consumidores crónicos de paco y cocaína: estudio de casos y controles / [Changes in cerebral hemodynamics in chronic users of \"PACO\" and cocaine: case-control study].

OBJECTIVE: To assess if there are changes in brain hemodynamics evaluated by means of transcranial doppler’s flow velocity, pulsatile index and cerebral perfusion pressure, between cocaine chronic abusers and healthy volunteers. METHOD: Prospective, case and control, observational study. Sex, age, user history, vital signs and transcranial doppler findings.Statistical analysis was performed by means of normality test, Wilcoxon’s test for non parametric samples and T Student test. RESULTS: Fifty-three abusers and 35 healthy volunteers were studied. Statistical differences were found for a diminish in age(p=0.008) and cerebral perfusion pressure in all cerebral arteries (p