Impact on patient outcome of emergency department length of stay prior to ICU admission.

OBJECTIVE: The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN: A single-center ambispective cohort study was carried out. SETTING: A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS: We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS: Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES: Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS: Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS: A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.

Utilización de noradrenalina y vasopresina en la prevención secundaria y el manejo conservador del fracaso renal agudo / Use of noradrenaline and vasopresin in secondary prevention and conservative management of acute renal failure

La lesión renal secundaria en el contexto del FRA se define como «cualquier daño renal adicional que se desarrolla en el transcurso de un daño renal primario». La naturaleza de la prevención del daño secundario depende del proceso que ha generado el FRA. Muchas veces, de hecho, es completamente imposible diferenciar el daño secundario del primario; por lo que las medidas de prevención deben ir encaminadas a proteger el riñón de forma evolutiva, previniendo el daño secundario y alterando la secuencia natural del insulto primario. Los fenómenos de hipoperfusión e isquemia son los mecanismos de lesión que generalmente se encuentran en la génesis de la disfunción renal, por ello, deberán ser nuestro objetivo primario de prevención. La presión arterial media (PAM) es el primer objetivo potencial de actuación. Existe evidencia de nivel III que nos dice que una PA sistólica (PAS) inferior a 80 mmHg (cifra equivalente a una PAM > 65 mmHg) es un factor independiente asociado al aumento de riesgo de desarrollar FRA. Existen así mismo pequeñas series de casos y estudios aleatorizados cruzados (evidencia de nivel II) que demuestran una relación entre el incremento de la PAM y mejoría de la función renal en algunos contextos clínicos. Sin embargo, también evidencia de nivel II nos dice que elevaciones por encima de 65 mmHg de PAM en el contexto del shock séptico con FRA, no consiguen mejorías en el aclaramiento de creatinina a corto plazo. Un pequeño estudio randomizado más reciente compara de forma controlada si la PAM superior a 85 mmHg es mejor que la PAM > 65 mmHg (usando noradrenalina) en la evolución renal de los pacientes sépticos (14 pacientes en cada brazo). No se encuentran diferencias entre los dos grupos. Podríamos completar nuestras recomendaciones iniciales diciendo que debemos preservar la perfusión renal mediante la optimización del GC, la PAM y el volumen intravascular (Grado de recomendación C). No deberíamos utilizar fármacos que induzcan vasodilatación renal selectiva (Grado A). Los vasopresores deben iniciarse una vez asegurado un relleno vascular adecuado (Grado C); epinefrina y fenilefrina no deben usarse como agentes de primera línea (Grado B); la dobutamina es el agente de elección para incrementar el gasto cardíaco (Grado C). Existe un pequeño estudio randomizado-controlado (evidencia de nivel II) que compara la noradrenalina con la dopamina a dosis alfa en 32 pacientes consecutivos con shock séptico. Los autores demuestran que la noradrenalina consigue restaurar la PAM de los pacientes mejor que la dopamina de forma significativa, y que dicho objetivo se asocia con un incremento significativo de la diuresis. Incluso, la asociación de noradrenalina en 10 pacientes de los once en que la dopamina había sido inefectiva, consigue revertir la situación. La noradrenalina es, pues, la droga de elección para revertir la situación de shock en nuestros pacientes (Recomendación de grado B). No existe evidencia de que revertir la hipotensión arterial con NA tenga un efecto perjudicial sobre la perfusión mesentérica o renal. De hecho, datos de experimentación animal muestran un incremento del flujo renal con el uso de la NA para revertir el shock séptico. La Vasopresina (VP) es una hormona de estrés endógena cuya secreción es importante ante estados de shock. La lógica de su uso en el paciente crítico es la existencia de un déficit endógeno de la misma en el contexto del shock distributivo, y que su administración exógena puede restaurar el tono vascular. Esta droga puede ser efectiva para revertir el shock cuando las catecolaminas son inefectivas, especialmente en el contexto de la sepsis. Aunque son varios los trabajos que han estudiado el potencial efecto presor de la VP en pacientes con shock séptico, ninguno de ellos ha demostrado hasta la fecha un efecto positivo en la mortalidad de los pacientes, aunque todos parecen demostrar un beneficio hemodinámico y en el flujo urinario. No existe evidencia suficiente, pues, en el momento actual para conocer cuál es el papel de la vasopresina en la prevención secundaria y el manejo conservador del fracaso renal agudo

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Indicaciones y aspectos logísticos de técnicas de depuración extracorpórea en el paciente agudo / Current indications of extracorporeal depuration in acute patients

Las técnicas de depuración extracorpórea que tenemos a nuestra disposición se pueden resumir en: Hemodiálisis Intermitente —HDI—, Diálisis Peritoneal —DP— y técnicas continuas —TCDE—; principalmente hemofiltración y hemodiafiltración continuas —HFVVC y HDFVVC—. Además de un conjunto de técnicas menos extendidas pero más sofisticadas encaminadas a tratar problemas concretos, como el fallo hepático (es el caso de la diálisis con albúmina —MARS®, Gambro-Hospal— o el sistema Prometheus®, de Fresenius Medical Care) o la sepsis con técnicas que comprenden la adsorción de moléculas. De estas últimas, se habla en extenso en el capítulo 6 de estas GUÍAS promovidas por la Sociedad Española de Nefrología. En la actualidad, la mayor incidencia de casos de pacientes con Fracaso Renal Agudo en un Hospital se presentan en Unidades de Cuidados Intensivos o Pacientes Críticos. En estas unidades, como lo evidencian los más recientes estudios epidemiológicos1- 3, se emplean mayoritariamente técnicas continuas. En el estudio multicéntrico y multinacional prospectivo sobre casi treinta mil ingresos en unidades de cuidados críticos, se observó que casi el 6% de los pacientes ingresados presentaban FRA y de entre ellos el 72% necesitaron tratamiento sustitutivo. Siendo tratados con TCDE el 80% de los casos, con HDI el 17% y tan solo el 3% de ellos con Diálisis Peritoneal1

Severe Acute Renal Failure (ARF) can be managed by intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT) or peritoneal dialysis (PD). The latter remains to be an alternative only in pediatrics and is anecdotic for adults in developed countries. Oliguria (urine output less than 200 mL/12h or 400 mL/day) seems to be the most frequent indication of renal replacement therapy, followed by uremia (blood urea greater than 33 mMol/L) and finally by electrolyte disturbances. Acute intoxications such as lithium, N-acetyl-procainamide, ethylenglycol or methanol can be effectively managed by these techniques. Whether or not CRRT compared with IHD improves outcome is controversial. At least in the most severely ill patients continuous therapies are better than intermittent ones and the former must be recommended if hemodynamic instability or cerebral edema are present. Regarding the dose: daily IHD seems to be better than the classical 3 per week scheme and in CRRT a dose of 35 mL·Kg-1·h-1 of effluent (convection only or ultrafiltration plus dialysis) is better than a lesser dose. CRRT have also been used in absence of acute renal failure in cases of sepsis, multiorgan failure syndrome, respiratory distress or fulminant hepatic failure. There is no strong evidence to support the use of these techniques on a regular basis to treat the aforementioned syndromes

Dosificación y modalidades de las TCDE / Dosing and CTED modalities

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Cytokines clearance during venovenous hemofiltration in the trauma patient.

The objective of the study was to investigate whether continuous venovenous hemofiltration (CVVH) would facilitate removal of substantial amounts of tumor necrosis factor (TNF) and interleukin-6 (IL-6) from the circulation in traumatized critically ill patients with multiple organ dysfunction syndrome. The study design was a prospective, nonblind, randomized controlled trial that was set in the trauma intensive care unit of a tertiary university referral hospital. Thirty consecutive critically ill, mechanically ventilated trauma patients with multiple organ dysfunction syndrome (without renal failure) were included in the study. Patients were randomized to either CVVH or conventional treatment. Blood and ultrafiltrate samples were collected from each patient before the initiation of CVVH and after 24, 72, and 168 hours of therapy. In the control group, blood samples were collected during the same periods. In the 30 patients studied, 15 had hemofiltration and 15 did not. Both groups were similar with regard to age (36+/-18 years v 36+/-14 years) and severity scores (injury severity score, 32+/-16 v 30+/-11; APACHE II score, 22+/-7 v 21+/-6; Goris score, 5.2+/-1.7 v 5.2+/-1.8). Before CVVH, TNF and IL-6 could be detected in the serum of all patients. The mean concentration of TNF was 17+/-22 pg/mL in patients and 22+/-20 pg/mL in control subjects (P = NS). The mean concentration of IL-6 was 2,153+/-2,824 pg/mL in patients and 1,774+/-1,637 pg/mL in control subjects (P = NS). We found a TNF and IL-6 substantial elimination with CVVH (excretion of TNF [microg/d] at 24, 48, and 168 hours: 112.6+/-161.2, 105.2+/-149.4, and 143.1+/-170.0; excretion of IL-6 [microg/d]: 1,655+/-719, 3,091+/-489, and 2,420+/-366). However, no significant difference was found in serum cytokines concentration between groups during the study: mean serum TNF concentration decreased from the pretreatment level to a mean level of 12+/-9.6 pg/mL in patients and 21+/-27 pg/mL in control subjects. Similar results were found with IL-6 concentration that decreased from the pretreatment level to a mean of 554+/-731 pg/mL in patients and 382 +/-568 pg/mL in control subjects. In conclusion, CVVH is associated with removal of substantial amounts of TNF and IL-6 from the circulation in traumatized critically ill patients, but the profile of these mediators is similar to that of controls, suggesting a nonclinically relevant elimination. Further prospective, randomized, clinical trials are needed to support our results.

Severe graft versus host disease following liver transplantation confirmed by PCR-HLA-B sequencing: report of a case and literature review.

A case of severe graft versus host disease in a liver transplant recipient is presented. Due to HLA similarity between donor and recipient, the demonstration of cellular chimerism had to be made by PCR-HLA-B sequencing. In addition, we review the literature on this entity emphasizing its poor outcome, the difficulty of the differential diagnosis, and the need for the development of new prophylactic and therapeutic strategies in its management.

Comparative study of propofol versus midazolam in the sedation of critically ill patients: results of a prospective, randomized, multicenter trial.

OBJECTIVES: To compare the effectiveness, characteristics, duration of action, hemodynamic and biochemical effects, and side effects of propofol and midazolam used for continuous intravenous sedation of ventilated critically ill patients. DESIGN: Multicenter, prospective, randomized, nonblinded study. SETTING: Nine Spanish general intensive care units (ICUs). PATIENTS: Ninety-eight patients admitted to the ICU who were mechanically ventilated and required sedation for a minimum of 48 hrs. INTERVENTIONS: Propofol or midazolam was used for induction and maintenance of continuous intravenous sedation for a maximum of 5 days. The effectiveness of those two regimens was assessed according to their effects on ventilatory management and the presence of agitation. MEASUREMENTS AND MAIN RESULTS: In 93% of the patients studied, there was a medical cause necessitating mechanical ventilation. The mean (+/-SD) duration of sedation was 81 +/- 25 hrs and 88 +/- 27 hrs for the propofol and midazolam groups, respectively. The induction dose was 2.24 +/- 0.43 mg/kg over 318 +/- 363 secs for propofol, and 0.22 +/-0.07 mg/kg over 33 +/-29 secs for midazolam. The maintenance dose was 2.8 +/-1.1 mg/kg/hr for propofol and 0.14 +/- 0.10 mg/kg/hr for midazolam. There was no difference regarding the opiate and muscle relaxant requirements between the two groups. Sedation with propofol was more effective in achieving patient-ventilator synchrony than that with midazolam after the first hour of treatment (p < .01). Patients sedated with propofol awoke more rapidly and with less variability that those patients sedated with midazolam (23 +/- 16 mins vs. 137 +/- 185 mins, respectively, p < .05), particularly in those patients requiring deep sedation (27 +/- 16 mins vs. 237 +/- 222 mins, respectively, p < .01). No hemodynamic or biochemical changes were detected in any of the treatment groups. During induction, five patients in the propofol group and two patients in the midazolam group had hypotension. CONCLUSIONS: In this population of critically ill patients, propofol is an effective and safe alternative for sedation, with some advantages, such as short duration of action and high effectiveness over the conventional regimen with benzodiazepines and opiates.