Clinical evaluation of peripheral tissue perfusion as a predictor of mortality in sepsis and septic shock in the intensive care unit: Systematic review and meta-analysis / Evaluación clínica de la perfusión tisular periférica como predictor de mortalidad en sepsis y choque séptico en la unidad de terapia intensiva: Revisión sistemática y metaanálisis

Objective: To determine the diagnostic performance of the clinical evaluation of peripheral tissue perfusion in the prediction of mortality. Design: Systematic review and meta-analysis. Setting: Intensive care unit. Patients and participants: Patients with sepsis and septic shock. Intervention: Studies of patients with sepsis and/or septic shock that associated clinical monitoring of tissue perfusion with mortality were included. A systematic review was performed by searching the PubMed/MEDLINE, Cochrane Library, SCOPUS, and OVID databases. Main variables of interest: The risk of bias was assessed with the QUADAS-2 tool. Sensitivity and specificity were calculated to evaluate the predictive accuracy for mortality. Review Manager software version 5.4 was used to draw the forest plot graphs, and Stata version 15.1 was used to build the hierarchical summary receiver operating characteristic model. Results: Thirteen studies were included, with a total of 1667 patients and 17 analyses. Two articles evaluated the temperature gradient, four evaluated the capillary refill time, and seven evaluated the mottling in the skin. In most studies, the outcome was mortality at 14 or 28 days. The pooled sensitivity of the included studies was 70%, specificity 75.9% (95% CI, 61.6%–86.2%), diagnostic odds ratio 7.41 (95% CI, 3.91–14.04), and positive and negative likelihood ratios 2.91 (95% CI, 1.80–4.72) and 0.39 (95% CI, 0.30–0.51), respectively. Conclusions: Clinical evaluation of tissue perfusion at the bedside is a useful tool, with moderate sensitivity and specificity, to identify patients with a higher risk of death among those with sepsis and septic shock. (AU)

Objetivo: Determinar el rendimiento diagnóstico de la evaluación clínica de la perfusión tisular periférica en la predicción de mortalidad. Diseño: Revisión sistemática y metaanálisis. Ámbito: Unidad de cuidados intensivos. Pacientes y participantes: Pacientes con sepsis y shock séptico. Intervenciones: Se incluyeron estudios de pacientes con sepsis y/o shock séptico que asociaron la monitorización clínica de la perfusión tisular con la mortalidad. Se realizó una revisión sistemática buscando en las bases de datos PubMed/MEDLINE, Cochrane Library, SCOPUS y OVID. Variables de interés principales: El riesgo de sesgo se evaluó con la herramienta QUADAS-2. Se calcularon la sensibilidad y la especificidad para evaluar la precisión predictiva de la mortalidad. Resultados: Se incluyeron trece estudios, con un total de 1667 pacientes y 17 análisis. Dos artículos evaluaron gradiente de temperatura, cuatro evaluaron tiempo de llenado capilar y siete evaluaron moteado en la piel. La mayoría de los estudios midieron mortalidad a 14 o 28 días. La sensibilidad agrupada de los estudios incluidos fue 70% y especificidad 75,9% (IC del 95%, 61,6%–86,2%), la razón de probabilidad diagnóstica 7,41 (IC del 95%, 3,91–14,04) y la razón de probabilidad positiva y negativa 2,91 (IC del 95%, IC, 1,80–4,72) y 0,39 (IC 95%, 0,30–0,51), respectivamente. Conclusiones: La evaluación clínica de la perfusión tisular es una herramienta útil, con sensibilidad y especificidad moderadas, para identificar pacientes con sepsis y shock séptico con mayor riesgo de muerte. (AU)

Clinical evaluation of peripheral tissue perfusion as a predictor of mortality in sepsis and septic shock in the intensive care unit: Systematic review and meta-analysis.

OBJECTIVE: To determine the diagnostic performance of the clinical evaluation of peripheral tissue perfusion in the prediction of mortality. DESIGN: Systematic review and meta-analysis. SETTING: Intensive care unit. PATIENTS AND PARTICIPANTS: Patients with sepsis and septic shock. INTERVENTIONS: Studies of patients with sepsis and/or septic shock that associated clinical monitoring of tissue perfusion with mortality were included. A systematic review was performed by searching the PubMed/MEDLINE, Cochrane Library, SCOPUS, and OVID databases. MAIN VARIABLES OF INTEREST: The risk of bias was assessed with the QUADAS-2 tool. Sensitivity and specificity were calculated to evaluate the predictive accuracy for mortality. Review Manager software version 5.4 was used to draw the forest plot graphs, and Stata version 15.1 was used to build the hierarchical summary receiver operating characteristic model. RESULTS: Thirteen studies were included, with a total of 1667 patients and 17 analyses. Two articles evaluated the temperature gradient, four evaluated the capillary refill time, and seven evaluated the mottling in the skin. In most studies, the outcome was mortality at 14 or 28 days. The pooled sensitivity of the included studies was 70%, specificity 75.9% (95% CI, 61.6%-86.2%), diagnostic odds ratio 7.41 (95% CI, 3.91-14.04), and positive and negative likelihood ratios 2.91 (95% CI, 1.80-4.72) and 0.39 (95% CI, 0.30-0.51), respectively. CONCLUSIONS: Clinical evaluation of tissue perfusion at the bedside is a useful tool, with moderate sensitivity and specificity, to identify patients with a higher risk of death among those with sepsis and septic shock. REGISTRATION: PROSPERO CRD42019134351.

Ventilación mecánica invasiva en pacientes con COVID-19 en un hospital privado de México. Una serie de casos: descripción y evolución de un protocolo de intubación temprana / Invasive mechanical ventilation in patients with COVID-19 in a private hospital in Mexico. A case series: description and evolution of an early intubation protocol / Ventilação mecânica invasiva em pacientes com COVID-19 em um hospital privado no México. Uma série de casos: descrição e evolução de um protocolo de intubação precoce

Resumen: La mortalidad de los pacientes de COVID-19 en ventilación mecánica y las estrategias empleadas varían en la literatura. El objetivo de esta serie de casos es describir el curso clínico de pacientes en ventilación mecánica invasiva con COVID-19 y su desenlace a 28 días. Se incluyeron 21 pacientes con un promedio de edad de 49 ± 13 años, 81% de sexo masculino y 38% con al menos una comorbilidad. Las variables ventilatorias iniciales fueron PaO2/FiO2 de 135 ± 53, PEEP 12 cmH2O, presión meseta 26 ± 4.8 cmH2O, distensibilidad estática 32 ± 8.5 mL/cmH2O, driving pressure 15 ± 3.9 cmH2O y poder mecánico 19.2 ± 4 J/min. El 67% de los pacientes estuvieron en posición prono y en 76% se empleó bloqueante neuromuscular. Los desenlaces a 28 días fueron 21 días libres de ventilación mecánica y 14% de mortalidad.

Abstract: The mortality and ventilation strategies of COVID-19 ARDS vary in the literature. The objective of this case series is to describe the clinical course of patients on invasive mechanical ventilation with COVID-19 and its outcome at 28 days. Twenty-one patients were included with an average age of 49 ± 13 years, 81% male and 38% with at least one comorbidity. The initial ventilatory variables were PaO2/FiO2 of 135 ± 53, PEEP 12 cmH2O, plateau pressure 26 ± 4.8 cmH2O, static compliance 32 ± 8.5 mL/cmH2O, driving pressure 15 ± 3.9 cmH2O, and mechanical power 19.2 ± 4 J/min. 67% of the patients received prone position and in 76% a neuromuscular blocker was used. The 28-day outcomes were 21 days of mechanical ventilation-free days and 14% mortality.

Resumo: A mortalidade de pacientes com COVID-19 em ventilação mecânica e as estratégias utilizadas variam na literatura. O objetivo desta série de casos é descrever a evolução clínica de pacientes em ventilação mecânica invasiva com COVID-19 e sua evolução em 28 dias. Incluíram-se 21 pacientes com média de idade de 49 ± 13 anos, 81% do sexo masculino e 38% com pelo menos uma comorbidade. As variáveis ventilatórias iniciais foram PaO2/FiO2 135 ± 53, PEEP 12 cmH2O, pressão de platô 26 ± 4.8 cmH2O, complacência estática 32 ± 8.5 mL/cmH2O, pressão motriz 15 ± 3.9 cmH2O e potência mecânica 19.2 ± 4 J/min. 67% dos pacientes estavam em decúbito ventral e em 76% foi utilizado bloqueador neuromuscular. Os resultados aos 28 dias foram 21 dias sem ventilação mecânica e 14% de mortalidade.

Early management of critically ill patients with COVID-19.

Coronavirus disease 2019 (COVID-19) is associated with a severe acute respiratory condition requiring respiratory support and mechanical ventilation. Based on the pathophysiology and clinical course of the disease, a therapeutic approach can be adapted. Three phases have been identified, in which different strategies are recommended in a stepwise invasiveness approach. In the second or acute phase, patients are frequently admitted to the ICU for severe pneumonia and hypoxemia with evidence of a proinflammatory and hypercoagulable state. This stage is an opportunity to intervene early in the disease. Medical strategies and mechanical ventilation should be individualized to improve outcomes.

Asociación y valor predictivo del poder mecánico con los días libres de ventilación mecánica / Association and predictive value of mechanical power with ventilator-free days / Associação e valor preditivo do poder mecânico com os dias livres de ventilação mecânica

Resumen Introducción: La afección pulmonar atribuible a la ventilación mecánica (VM) ha sido denominada lesión pulmonar asociada con la ventilación mecánica (LPAVM). La fórmula del poder mecánico (PM) reúne las principales variables que determinan el desarrollo de la LPAVM. Analizamos la correlación entre el PM y los días libres de ventilación mecánica (DLVMI), así como la capacidad de predicción para DLVMI. Material y métodos: Se estudiaron 40 pacientes ingresados a la unidad de terapia intensiva (UTI) y que cumplieron con los criterios de inclusión. Se recabaron las variables demográficas, clínicas y de laboratorio. Se realizó el cálculo del poder mecánico en las primeras 24 horas de estancia en la UTI y se determinaron los DLVMI, estancia en la UTI y mortalidad en la UTI. Se realizó la prueba de rho de Spearman para determinar la correlación entre PM y DLVM; análisis multivariado de regresión binaria. Para evaluar la capacidad predictiva de las variables que se relacionaron de forma independiente, se compararon las áreas bajo la curva en la curva de características operativas del receptor (ROC). Resultados: PM y DLVM tienen correlación inversa de magnitud intermedia. Se asociaron de manera independiente: PM OR 2.07, IC 95% (1.10-4.09), p = 0.01, frecuencia respiratoria OR 1.5, IC 95% (1.05-2.3), p = 0.04 y Vt/kg (≤ 8.2 mL) un OR 0.01, IC 95% (0.001-0.10), p = 0.002. El área bajo la curva (ABC) fue PM (ABC) 0.75, IC 95% (0.59-0.90), p = 0.007, FR (ABC) 0.71, IC 95% (0.54-0.88), p = 0.01 y Vt/kg (ABC) 0.92, IC (0.83-1.0), p = 0.001. Conclusión: El poder mecánico se correlaciona de forma inversa con los días libres de ventilación mecánica, con adecuada capacidad predictiva para días libres de ventilación mecánica invasiva, con un punto de corte en 13 Joules/min.

Abstract Introduction: Pulmonary disease attributable to mechanical ventilation (MV) has been named ventilator-associated lung injury (VALI). The mechanical power formula (MP) brings together the main variables that determine VALI development. It analyzes the correlation between MP and ventilator-free days (VFD), as well as the predictive capacity for VFD. Material and methods: We studied 40 patients admitted to the intensive care unit (ICU) and who met the inclusion criteria. Demographic, clinical and laboratory data were collected. MP calculation was performed in the first 24 hours of ICU stay and we determined VFD, ICU stay and ICU mortality. The Spearman's rho test was performed to determine the correlation between MP and VFD; we performed the bi-varied and later multivariate binary regression analysis. To evaluate the predictive capacity of the variables that were independently related, we compared the areas under the curve (AUC) in the receiver operating characteristics (COR) curve. Results MP and VFD have an inverse correlation with intermediate magnitude. They were independently associated: MP OR 2.07, 95% CI (1.10-4.09), p = 0.01, respiratory rate OR 1.5, 95% CI (1.05-2.3), p = 0.04 and Tv/ kg (≤ 8.2 mL) OR 0.01, 95% CI (0.001-0.10), p = 0.002. MP (AUC) 0.75, 95% CI (0.59-0.90), p = 0.007, respiratory rate (ABC) 0.71, 95% CI (0.54-0.88), p = 0.01 and Tv/kg (ABC) 0.92, IC (0.83-1.0), p = 0.001. Conclusion: MP and VFD have inverse correlation, with ability for predicting VFD, with a cutoff point of 13 Joules/min.

Resumo Introdução A alteração pulmonar induzida pela ventilação mecânica (VM) definiu-se como lesão pulmonar associada à ventilação (LPAV). A fórmula do poder mecânico (PM) reúne as principais variáveis que determinam o desenvolvimento da LPAV. Analisamos à correlação entre PM e os dias livres de ventilação mecânica (DLVM), assim como a capacidade de previsão para DLVM. Métodos Estudamos 40 pacientes internados na unidade de terapia intensiva (UTI) e que completaram os critérios de inclusão. Foram coletados dados demográficos, clínicos e laboratoriais. O cálculo do PM foi realizado nas primeiras 24 horas da internação na UTI e determinamos DLVM, permanência e mortalidade na UTI. O teste de rho Spearman foi realizado para determinar a correlação entre PM e DLVM; análise multivariada de regressão binária. Para avaliar a capacidade preditiva das variáveis que se relacionaram de maneira independente, comparamos as áreas sob a curva na curva de características operativas do receptor (COR). Resultados PM e DLVM têm correlação inversa de magnitude intermediária. Se associaram de maneira independente: PM OR 2.07, IC 95% (1.10-4.09), p = 0.01, frequência respiratória OR 1.5, IC 95% (1.05-2.3), p = 0.04 e Vt/kg (< 8.2 mL) um OR 0.01, IC 95% (0.001-0.10), p = 0.002. Na área sob a curva (ABC) foi PM (ABC) 0.75, IC 95% (0.59-0.90), p = 0.007, FR (ABC) 0.71, IC 95% (0.54-0.88), p = 0.01 e Vt/kg (ABC) 0.92, IC (0.83-1.0), p = 0.001. Conclusões O poder mecânico têm correlação inversa com os dias livres de ventilação mecânica, com adequada capacidade preditiva para os dias livres de ventilação mecânica invasiva, com um ponto de corte de 13 Joules/min.

Ultrasonografía del musculoesquelético como valoración nutricional en el paciente crítico / Skeletal muscle ultrasound as a nutritional assessment in the critically ill patient / Ultra-som muscúlo esquelético como valoração nutricional no paciente crítico

Resumen: Introducción: El paciente crítico se caracteriza por una respuesta catabólica aumentada de origen multifactorial, la cual incrementa la pérdida muscular. El ultrasonido a la cabecera del paciente es una herramienta útil para medir el desgaste muscular, evaluar y dar seguimiento nutricional. Material y métodos: Estudio prospectivo y descriptivo con una intervención diagnóstica de bajo riesgo. Se realizaron mediciones del grosor del músculo cuádriceps de una muestra de 20 pacientes consecutivos, se dividieron dos grupos, el grupo 1 con 11 pacientes que tuvieron desgaste muscular representado en porcentaje y en el grupo 2 nueve pacientes sin desgaste muscular. Resultados: En el análisis univariado sólo se observó diferencia entre ambos grupos en el día en que se lograron las metas de nutrición, fue tardío en el grupo de pacientes con desgaste muscular (5 [5-5.5, IC 95%] y 3 [2.5-5, IC 95%] con p = 0.02). En el análisis multivariado se corrobora la misma asociación, pero sin significancia estadística (RM 10.8 [0.93-125-68, IC 95%]). En el análisis de correlación se encontró una relación inversa entre el puntaje de SOFA y el porcentaje de desgaste muscular (r = -0.48 y r2 = 0.23). Conclusiones: El estudio reveló una posible asociación entre la presencia de desgaste muscular en el paciente crítico y el retraso en alcanzar las metas de nutrición. Y una relación inversa entre el valor del puntaje de SOFA y el porcentaje de pérdida muscular.

Abstract: Introduction: The critically ill patient is characterized by an increases catabolic response whith multifactorial origin, which increases muscle loss. Ultrasound at the bedside is a useful tool for measuring muscle wasting, and assess nutritional goals. Material and methods: A prospective study with a low risk diagnostic intervention. We measure the thickness of the quadriceps muscle of a sample of 20 consecutive patients. Two groups were divided, in group 1 with 11 patients who had muscle wasting represented in percentage and group 2 with 9 patients without muscle wasting. Results: In univariate analysis only difference was found between the two groups on the day they were achieved nutrition goals, and was late for the group of patients with muscle wasting (5 [5-5.5; 95%] and 3 [2.5-5, 95% CI] p = 0.02). In multivariate analysis corroborates the same association, but without statistical significance (RM 10.8 [0.93-125-68, 95% CI]). For the correlation analysis an inverse relationship between SOFA score and the percentage of muscle wasting (r = -0.48 and r2 = 0.23) was found. Conclusions: In the study a possible association was met between the presence of muscle wasting in critically ill patients and delay in achieving nutrition goals. And inverse relationship between the value of SOFA score and the percentage of muscle loss.

Resumo: Introdução: O paciente crítico se caracteriza por um aumento da resposta catabólica multifatorial, o que aumenta a perda de massa muscular. O ultra-som à beira do leito é uma ferramenta útil para medir a perda de massa muscular, avaliar e dar monitoramento nutricional. Material e métodos: Estudo prospectivo descritivo com uma intervenção diagnóstica de baixo risco. Realizaram-se medições da espessura do músculo quadríceps de uma amostra de 20 pacientes consecutivos, foram divididos em dois grupos, grupo 1 com 11 pacientes que tiveram perda de massa muscular representada em porcentagem e no grupo 2 com 9 pacientes sem perda de massa muscular. Resultados: A análise univariada só encontrou diferença entre os dois grupos no dia em que foram alcançadas as metas nutricionais, foi tardío para o grupo de pacientes com perda de massa muscular (5 [5-5.5, IC 95%] e 3 [2.5-5, IC 95%] com p = 0.02). A análise multivariada comprova a mesma associação, mas sem significado estatístico (RM 10.8[0.93-125-68, IC 95%]). Para a análise de correlação encontrou-se uma relação inversa entre SOFA escore e a percentagem de perda de massa muscular (r = -0.48 e r2 = 0.23). Conclusões: Encontrou-se uma possível associação entre a presença da perda de massa muscular em pacientes críticos e o atraso em lograr as metas de nutrição. E relação inversa entre o valor SOFA escore e a porcentagem da perda de massa muscular.