[Non-glucose carbohydrates in the parenteral nutrition of patients with systemic inflammatory response syndrome]. / Hidratos de carbono no-glucosa en la nutrición parenteral de pacientes con síndrome de respuesta inflamatoria sistémica.

OBJECTIVE: To compare tolerance of two sources of isocaloric intake (fructose-glucose-xylitol mixture [FGX] versus glucose) in parenteral nutrition for patients with systemic inflammatory response syndrome (SIRS). DESIGN: Open, prospective, cohort and randomized study. SETTING: Intensive Care Unit. SUBJECTS AND METHODS: Two groups of patients admitted in ICU: acute pneumonia with sepsis, and necro-hemorrhagic pancreatitis. Criteria of exclusion were: diabetes, previous hypertriglyceridemia, renal failure with serum creatinine > 3 mg/dL on admission in ICU, or hyperbilirrubinemia > 2.5 mg/dL. Parenteral nutrition (TPN), consisting of 1.4 g AA + Lipids 1.3 g + carbohydrates 4 g/kg/d, (either glucose or FGX at random) was administered. Basal levels and days 1st, 4th and 10th plasma glucose, triglycerides, cholesterol, uric acid were determined, and blood venous gases as well. Capillary glycemia was measured every 6 hours and insulin given if glucose levels rose above 180 mg/dL. STATISTICS: Fisher's exact test; Student t-test; Mann-Whitney test. Data as mean and SD. RESULTS AND CONCLUSIONS: During 48 months, 119 patients admitted in the ICU (72 with pneumonia and 47 with pancreatitis) were included. In pneumonia, tolerance was similar with both intakes; glycemia was kept at the same level in both, but the amount of insulin given was significantly more in those patients fed on glucose (p < 0.05). Nevertheless, resting blood glucose and triglyceride levels were higher in pancreatitic patients, and more insulin was required. Those on FGX had lower triglyceride plasma levels (p < 0.05) and less insulin was given throughout the study. Glycemia was kept lower though no statistical significance was reached (p < 0.1). No hyperuricemia nor lactic acidosis was found.

[Prognostic value of 2 patient classification systems: APACHE II and diagnosis-related groups]. / Valor pronóstico de dos sistemas de clasificación de pacientes: APACHE II y grupos relacionados con el diagnóstico.

UNLABELLED: The APACHE II system classified patients on the basis of the severity of their disease, while the groups related with the diagnosis (DRG) are classified according to the consumption of resources. Nonetheless, the relative DRG weight (RWDRG) may be related with severity given that the most severe patients are also usually the most expensive. The aims of the study were: 1) verify the ability of DRG to measure clinical severity and 2) compare the prognostic value of both systems. METHODS: A transversal cut off was performed (316 consecutive admissions in intensive care units [ICU] with 23 exclusions due to unclear final evolution) with the patients being classified according to final hospital evolution in survivors and deaths. Each patient was given an APACHE II score corresponding to the first 24 hours in the ICU. Parallelly the cases were grouped in the corresponding DRG in accordance with the CIE-9-MC codification of their discharge report. The comparison of the means was carried out with the Student's t test, with the determination of prognostic values being performed by discriminant analysis. RESULTS: The survivors had an APACHE II score of 9.5 +/- 5.5 and the deaths of 22.5 +/- 7.8 (p < 0.0001). The RWDRG of the survivors was 1.4 +/- 0.9 and that of the deaths of 2.0 +/- 1.0 (p < 0.0001). On inclusion of all the patients the APACHE II prognostic value was 85.3% and the RWDRG 68.9% and both 84.6%. In the group of patients with a RWDRG lower than 1.6 the prognostic value of the APACHE II was of 87.6% and the RGRDW 72.0% and both 90%. In the group with RWDRG greater than 1.6 the prognostic value of the APACHE II was 85.1%, the RWDRG 73.0% and both 83.2%. CONCLUSIONS: The system of the groups related with diagnosis indirectly measures clinical severity. APACHE II is significantly superior to the system of groups related with diagnosis with regard to prognostic value. The use of both systems together does not improve the prognostic value of APACHE II.

[Analysis of public health expenditures in the area of Guadalajara during the fiscal year 1989]. / Análisis del gasto sanitario público en el área de Guadalajara durante el ejercicio 1989.

In the health care area of Guadalajara health expenses are met by three agencies, although there are no local data on the participation of each of them. The present paper studies public expenditures in Guadalajara, as well as their distribution by agency, by budget items and by type of service during 1989, and their relationship with population size and the gross provincial product. Total expenditures amounted 9.085.343.426 ptas. of which the National Health Institute (INSALUD) provided 80.5%, the Regional Health Council 15.5% and the County Council 4%. This implies a health expenditure of 61.385 ptas per year (21.424 ptas for primary care, 36.278 ptas for specialized care 3.683 ptas for overheads and administrative costs). The gross provincial product amounted to 122.5 billion ptas of which 7.65% were allocated to health care. Guadalajara is a large area with a small but widely dispersed and regressive population moderately depressed from the economic point of view, and with overall health resources above national average. Distribution of health care expenditure coincides with the overall data provided by the direct management of INSALUD. The expenditure/inhabitant ratio is higher than the national average, both in absolute terms and in percentage of the gross provincial product, which is understandable when demographic characteristics and existing resources are considered.

Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste.

A comparative, prospective study was made of the incidence of infection in the lower airway (purulent tracheobronchitis and pneumonia) in long-term patients who were mechanically ventilated due to respiratory failure of noninfectious origin. Twenty-eight patients were randomly allocated into a study group (A, n = 13) in which a nonabsorbable paste containing 2% tobramycin, 2% amphotericin B, and 2% polymyxin E was administered locally to decontaminate the oropharynx, and a control group (B, n = 15) in which a paste without antibiotics was also applied to the oropharynx. We studied the effectiveness of the prophylactic technique in decontaminating the oropharynx and trachea of organisms potentially pathogenic for the respiratory system. Decontamination was successful in ten of 13 patients in group A vs. one of 15 patients in group B (p less than .001). The results demonstrated a lower rate of infection in the lower respiratory tract in the study group (three patients with tracheobronchitis and no pneumonias) than in the control group (three patients with tracheobronchitis and 11 with pneumonia), the difference between both being highly significant (p less than .001). Two (15%) patients in group B developed sepsis of pulmonary origin. None of the patients on prophylactic treatment developed this complication. Although the overall mortality was similar in both groups (group A, 30% vs. group B, 33%), we believe that infection contributed to a great extent to the death of two of five patients in group B. We conclude that nosocomial pneumonia, which is a frequent complication in critically ill patients on mechanical ventilation, could be prevented by local application of nonabsorbable antibiotics to the oropharynx.