Extracorporeal membrane oxygenation (ECMO) in adults with acute respiratory distress syndrome (ARDS): A 6-year experience and case-control study.

PURPOSE: To evaluate the development of an extracorporeal membrane oxygenation (ECMO) program for the treatment of acute respiratory distress syndrome (ARDS) in adults. METHODS: a) Descriptive study of 15 cases treated since the program approval from 2010 to 2016. b) Case-control study matching the 15 ECMO cases with the 52 severe ARDS treated between 2005 and 2011 in which alternative rescue treatments (prone ventilation, tracheal gas insufflation (TGI) and/or the administration of inhaled nitric oxide (iNO)) were used. RESULTS: ECMO experience: Mortality 47% (7/15). Four patients died due to complications directly related to ECMO therapy. ICU stay 46.6 ± 45 days (range 4-138). Hospital stay 72.4 ± 98 days (range 4-320). Case-control: The mortality in the control group was 77% (44/52). The ECMO group practically doubled the mean days of ICU and hospital stay (p < 0.05). The multivariate analysis demonstrated an OR of 0.13 (0.02-0.73) for mortality associated with ECMO treatment. The following were also independent predictors of mortality: age (OR 1.05, 95% CI 1-11), SOFA score (OR 1.34, 95% CI 1.04-1.7), and the need for renal replacement therapy (OR 1.3, 95% CI 1.04-1.7). Economic analysis: The hospital cost per patient in the ECMO group doubled compared to that of the control group (USD 77,099 vs USD 37,660). However, the cost per survivor was reduced by 4% (USD 144,560 vs USD 150,640, respectively). CONCLUSIONS: Our results endorse the use of ECMO as a rescue therapy in adults with ARDS, although there are some risks associated with a learning curve as well as an important increase in the days of patient stay. The justification for the maintenance of an ECMO program in adults should be based on future studies of efficacy and cost effectiveness.

Incidence and prognosis of intra-abdominal hypertension in critically ill medical patients: a prospective epidemiological study.

INTRODUCTION: The aim of this study was to determine the incidence of intra-abdominal hypertension (IAH) in patients with two or more categorized risk factors (CRF) for IAH, and their morbidity and mortality during their intensive care unit (ICU) stay. METHODS: Prospective cohort study carried out at a medical ICU. A total of 151 medical patients were enrolled during a period of 3 months. After ICU whole staff training, we conducted daily screening of the four CRF for IAH based on the World Society of Abdominal Compartment Syndrome (WSACS) guidelines (namely, diminished abdominal wall compliance, increased intraluminal content, increased abdominal content, and capillary leak syndrome or fluid resuscitation). In those patients with risk factors of at least two different categories (≥2 CRF), intra-abdominal pressure (IAP) was measured every 8 h during ICU stay. Data included demographics, main diagnosis on admission, severity scores, cumulative fluid balance, daily mean IAP, resolution of IAH, days of ICU and hospital stay, and mortality. RESULTS: Eighty-seven patients (57.6%) had ≥2 CRF for IAH, 59 (67.8%) out of whom developed IAH. Patients with ≥2 CRF had a significantly higher mortality rate (41.4 vs. 14.3%, p < 0.001). Patients with IAH had higher body mass index, severity scores, organ dysfunctions/failures, number of CRF for IAH, days of ICU/hospital stay and hospital mortality rate (45.8 vs. 32.1%, p = 0.22). Non-resolution of IAH was associated with a higher mortality rate (64.7 vs. 35.3%, p = 0.001). None of the cohort patients developed abdominal compartment syndrome. The multivariate analysis showed that IAH development (odds ratio (OR) 4.09; 95% confidence interval (CI) 0.83-20.12) was a non-independent risk factor for mortality, and its non-resolution (OR 13.15; 95% CI 22.13-81.92) was an independent risk factor for mortality. CONCLUSIONS: Critically ill medical patients admitted to ICU with ≥2 CRF have high morbidity, mortality rate, and incidence of IAH, so IAP should be measured and monitored as recommended by the WSACS. Our study highlights the importance of implementing screening and assessment protocols for an early diagnosis of IAH.

A simple educational intervention to decrease incidence of central line-associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI.

After an educational intervention in 3 intensive care units, 34 central line-associated bloodstream infections occurred in 11,582 central venous catheter [CVC]-days, compared with 45 episodes in 10,661 CVC-days before intervention (4.22 vs 2.94 episodes per 1,000 CVC-days [30.9% reduction]; P = .03, Wilcoxon rank sum test; P = .11, Poisson regression analysis).