Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation / Asociación entre la disfunción diastólica y el balance de hídrico en pacientes críticos durante el destete de la ventilación mecánica

Objective: To assess the role of diastolic dysfunction and fluid balance in weaning failure. Design: Prospective, observational, single center. Setting: Intensive care unit of a university hospital. Patients: Adult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). Interventions: Echocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. Main variable of interest: Weaning failure. Results: Among 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (−648 mL [−884 to -138] vs. −893 mL [−1284 to −501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (−973 mL [−1493 to −201] vs. −425 mL [−1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. Conclusions: Weaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario. (AU)

Objetivo: Evaluar el papel de la disfunción diastólica (DD) y el balance hídrico en el fracaso del destete de la ventilación mecánica. Diseño: Prospectivo, observacional.Ámbito: Unidad de cuidados intensivos hospital universitario. Pacientes: Pacientes adultos con ventilación mecánica más de 48 h sometidos a una prueba de respiración espontánea (SBT).Intervenciones: Ecocardiografía antes y al final del SBT. Los pacientes se clasificaron en dos grupos según el resultado del destete. Variable de interés principal: Fracaso del destete. Resultados: Se incluyeron 89 pacientes, el fracaso del destete ocurrió en 33 (37%). La DD al final de la SBT fue más frecuente en el grupo de fracaso (39,3% vs 17,8%, p = 0,025). El balance hídrico diario desde el ingreso en UCI hasta la SBT fue menos negativo en los pacientes que fracasaron que en los que tuvieron éxito del destete (−648 mL [-884 a -138] vs −893 mL [-1284 a -501], p = 0,007). El balance hídrico diario desde el primer SBT hasta el alta de UCI fue más negativo en el grupo de fracaso que en el de éxito (−973 ml [−1493 a −201] vs. −425 ml [−1065 a 12], p = 0,034). La regresión de Cox mostró que la DD no era un factor independiente relacionado con el fracaso, necesitando la asociación del balance hídrico y la edad. Conclusiones: El fracaso del destete debido a DD se relaciona con el balance hídrico, incrementando su efecto nocivo con la edad. El momento de inicio del balance hídrico negativo puede jugar un papel clave en el fracaso. (AU)

Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation.

OBJECTIVE: To assess the role of diastolic dysfunction and fluid balance in weaning failure. DESIGN: Prospective, observational, single center. SETTING: Intensive care unit of a university hospital. PATIENTS: Adult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). INTERVENTIONS: Echocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. MAIN VARIABLE OF INTEREST: Weaning failure. RESULTS: Among 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (-648 mL [-884 to -138] vs. -893 mL [-1284 to -501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (-973 mL [-1493 to -201] vs. -425 mL [-1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. CONCLUSIONS: Weaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario.

Nutrition intake in critically ill patients with coronavirus disease (COVID-19): A nationwide, multicentre, observational study in Argentina.

INTRODUCTION: In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with coronavirus disease (COVID-19) patients. METHODS: A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March and October 2020. INCLUSION CRITERIA: Adult ICU patients>18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48h. Statistical analysis was carried out using IBM-SPSS© 24 programme. RESULTS: One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97g/kg/day (CI 0.95-0.99), P<0.001), and lower caloric intake than those who survived (12.94kcal/kg/day (CI 12.48-13.39) vs 16.47kcal/kg/day (CI 16.09-16.8), P<0.001). A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II>18. CONCLUSIONS: Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.

Neumotórax a tensión secundario a colocación de sonda enteral: reporte de caso / Tension pneumothorax secondary to enteral tube: a case report / Pneumotórax hipertensivo secundário à colocação de sonda enteral: relato de caso

Resumen: La colocación de una sonda enteral es un procedimiento invasivo rutinario que puede presentar complicaciones graves. Presentamos el caso de un hombre de 54 años de edad que presentó paro cardiorrespiratorio secundario a infarto de miocardio y que, después de la colocación de una sonda nasoyeyunal, desarrolló neumotórax, por lo que ameritó su retiro, la colocación de una sonda endopleural y la administración de antibióticos. El paciente mostró adecuada expansión pulmonar, lo cual permitió el retiro de la sonda endopleural a los seis días de su instalación, la extubación del enfermo y finalmente su egreso por mejoría. El neumotórax asociado a la colocación de la sonda enteral se presenta en 1.2% de los pacientes. Los factores de riesgo son: déficit neurológico, alteración de la deglución y del reflejo tusígeno. El tratamiento descrito en la literatura es el retiro de la sonda, el uso de antibióticos y el drenaje torácico.

Abstract: Enteral tube placement is a routine invasive procedure that can present serious complications. We present the case of a 54-year-old man who presented with cardiorespiratory arrest secondary to myocardial infarction and who, after placement of a nasojejunal tube, developed pneumothorax that required removal of the tube, placement of a chest tube and administration of antibiotics. The patient presented adequate lung expansion, which allowed removal of the chest tube six days after its installation, extubation and finally discharge due to improvement. Pneumothorax associated with enteral tube placement occurs in 1.2% of patients. Risk factors are neurological deficit, impaired swallowing and cough reflex. Treatment described in the literature is removal of the tube, use of antibiotics and chest drainage.

Resumo: A colocação de sonda enteral é um procedimento invasivo de rotina que pode apresentar complicações graves. Apresentamos o caso de um homem de 54 anos que apresentou parada cardiorrespiratória secundária a infarto do miocárdio e que, após colocação de sonda nasojejunal, desenvolveu pneumotórax que exigiu sua retirada, colocação de sonda endopleural e administração de antibióticos.O paciente apresentou expansão pulmonar adequada, o que permitiu a retirada do tubo endopleural 6 dias após sua instalação, a extubação do paciente e por fim sua alta por melhora. O pneumotórax associado à colocação de sonda enteral ocorre em 1.2% dos pacientes. Os fatores de risco são: déficit neurológico, deglutição prejudicada e reflexo da tosse. O tratamento descrito na literatura é a retirada da sonda, uso de antibióticos e drenagem torácica.

Índices de oxigenación, índice de choque diastólico y tiempo en presión soporte como predictores de éxito en el retiro de la ventilación mecánica invasiva en paciente críticamente enfermo con COVID-19 / Oxygenation indices, diastolic shock index, and time in support pressure as predictors of success in the removal of invasive mechanical ventilation in critically ill patients with COVID-19 / Índices de oxigenação, índice de choque diastólico e tempo em pressão de suporte como preditores de sucesso na retirada de ventilação mecânica invasiva em pacientes em estado crítico com COVID-19

Resumen Introducción: El porcentaje de pacientes gravemente enfermos por COVID-19 que toleran el retiro de la ventilación mecánica es mínimo, por lo cual es fundamental determinar cuáles son los predictores de éxito en el retiro de la ventilación mecánica. Objetivos: Determinar si los índices de oxigenación, tiempo en presión soporte e índice de choque diastólico son predictores de éxito en el retiro de la ventilación mecánica en pacientes críticamente enfermos por COVID-19. Material y métodos: Estudio de cohorte prospectivo en pacientes con COVID-19 que ingresaron a la Unidad de Cuidados Intensivos y fueron sometidos a pruebas de ventilación espontánea, siendo posteriormente liberados del ventilador mecánico. Se recolectaron datos demográficos, resultados de laboratorio y parámetros ventilatorios con la finalidad de analizar y determinar predictores de éxito en el retiro de la ventilación mecánica. Resultados: Se observó una diferencia significativa entre los pacientes que toleraron y los que no toleraron el retiro de la ventilación mecánica en las siguientes variables: índice de respiración rápida superficial 47 ± 17.9 vs 90 ± 20.2 (p = 0.08), días de ventilación mecánica 5.8 vs 9.3 (p = 0.03), sesiones de prono 1.36 vs 2.33 (p = 0.058) y presión arterial diastólica 57 ± 3.6 (p = 0.027). Conclusión: En los pacientes críticamente enfermos por COVID-19 que son candidatos a retiro de la ventilación mecánica sugerimos usar como predictores de éxito: el índice de respiraciones rápidas superficiales < 64, días de ventilación mecánica < 8, presión arterial diastólica > 57 mmHg y haber tenido máximo dos sesiones de prono como predictores de éxito en el retiro de la ventilación mecánica.

Abstract Introduction: The percentage of critically ill patients due to COVID-19 who tolerate the withdrawal of mechanical ventilation is minimal. It is essential to determine which are the predictors of success in weaning. Objectives: To determine if the oxygenation indices, time in pressure support, and diastolic shock index are predictors of success in the withdrawal of mechanical ventilation in critically ill patients due to COVID-19. Material and methods: Prospective cohort study in patients with COVID-19 who were admitted to the ICU and underwent tests of spontaneous ventilation, being later released from the mechanical ventilator. Demographic data, laboratory results, ventilatory parameters were collected in order to analyze and determine predictors of success in weaning. Results: A significant difference was found between those who tolerated and those who did not tolerate the withdrawal of mechanical ventilation in the following variables: rapid shallow breathing index 47 ± 17.9 vs 90 ± 20.2 (p = 0.08), days of mechanical ventilation 5.8 vs 9.3 (p = 0.03), prone sessions 1.36 vs 2.33 (p = 0.058), diastolic blood pressure 57 ± 3.6 (p = 0.027). Conclusion: In critically ill patients due to COVID-19 who are candidates for withdrawal from mechanical ventilation, we suggest using as predictors of success: Index of rapid shallow breaths < 64, days of mechanical ventilation < 8, diastolic blood pressure > 57 mmHg and having had a maximum two prone sessions as predictors of success in the withdrawal of mechanical ventilation.

Resumo Introdução: A porcentagem de pacientes graves com COVID-19 que toleram a retirada da ventilação mecânica é mínima, por isso é essencial determinar os preditores de sucesso na retirada da ventilação mecânica. Objetivos: Determinar se os índices de oxigenação, tempo em pressão suporte, índice de choque diastólico são preditores de sucesso no desmame da ventilação mecânica em pacientes críticos com COVID-19. Material e métodos: Estudo de coorte prospectivo em pacientes com COVID-19 admitidos na unidade de terapia intensiva e submetidos a testes de ventilação espontânea e posteriormente liberados do ventilador mecânico. Foram coletados dados demográficos, resultados laboratoriais e parâmetros ventilatórios para analisar e determinar os preditores de sucesso no desmame da ventilação mecânica. Resultados: Observou-se uma diferença significativa entre os pacientes que toleraram e os que não toleraram a retirada da ventilação mecânica nas seguintes variáveis: índice de respiração rápida e superficial 47 ±17.9 vs 90 ± 20.2 (p = 0.08), dias de ventilação mecânica 5.8 vs 9.3 (p = 0.03), sessões de prona 1.36 vs 2.33 (p = 0.058) e pressão arterial diastólica 57 ± 3.6 (p = 0.027). Conclusão: Em pacientes em estado crítico com COVID-19 candidatos à retirada da ventilação mecânica, sugerimos usar como preditores de sucesso: índice de respirações rápidas e superficiais < 64, dias de ventilação mecânica < 8, pressão arterial diastólica > 57 mmHg e ter realizado no máximo 2 sessões em decúbito ventral como preditores de sucesso no desmame da ventilação mecânica.

Patrones de administración de vancomicina en pacientes críticamente enfermos / Vancomycin administration patterns in critically ill patients

Resumen La vancomicina es un antimicrobiano ampliamente utilizado en unidades de cuidado intensivo para el tratamiento de infecciones por cocos Gram positivos. El principal parámetro PK/PD, predictor de la actividad de la vancomicina, es el AUC/MIC mayor a 400, logrado mediante concentraciones plasmáticas del fármaco de 15 a 20 mg/l en el contexto de un paciente con función renal normal. En los pacientes críticos, se generan cambios en los patrones farmacocinéticos que llevan a dosis sub-terapéuticas del antibiótico y monitoreo constante de las concentraciones plasmáticas. Por tanto, se realizó una búsqueda de la literatura con el objetivo de conocer cuál es el mejor régimen de administración de vancomicina en pacientes críticamente enfermos y establecer los parámetros básicos de prescripción en esta población. Se encontró que la infusión continua de vancomicina se relacionó con mejores resultados, alcanzando más tempranamente los niveles planeados de concentración plasmática. La dosis de carga estuvo en el intervalo de 15 a 30 mg/k y la dosis de mantenimiento se dio en promedio entre 30 a 40 mg/K día. La concentración plasmática meta de vancomicina usada en la mayoría de los estudios oscila entre 15 y 20 mg/l. Como conclusión, se obtiene que la forma de administración en infusión continua, muestra mejor resultado, comparada con la administración intermitente; las dosis altas tanto en carga como en mantenimiento son las más recomendadas y no incrementan el riesgo de nefrotoxicidad; las estrategias PK/PD son útiles para el ajuste de la dosis de los pacientes críticamente enfermos.

Abstract Vancomycin is an antimicrobial used in intensive care units for the treatment of Gram-positive cocci infections. The main PK/PD parameter, predictor of vancomycin activity, is the AUC/MIC greater than 400; this is reached with plasma drug concentrations of 15 to 20 mg/l in the context of a patient with normal renal function. In critically ill patients, there are changes in the pharmacokinetic patterns that lead to sub-therapeutic doses of the antibiotic and a requirement for monitoring the vancomycin levels. There was reviewed literature on this field to determine the best vancomycin administration regimen in critically ill patients, and to establish the basic prescription parameters in this population. It was found that continuous infusion of vancomycin was associated with better results since it reached the necessary plasma concentration levels earlier. The loading dose was in the range of 15 to 30 mg/kg and the maintenance dose averaged between 30 to 40 mg/kg per day. The target plasma concentration of vancomycin used in most of the studies ranged between 15 and 20 mg/l. In conclusion, the continuous administration of vancomycin shows better results compared to intermittent administration. High doses in loading and maintenance are the most recommended since these do not increase the risk of nephrotoxicity. Finally, PK/PD strategies are useful for adjusting the dose of critically ill patients.

Effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults – A meta-analysis of randomized controlled trials with trial sequential analysis / Efecto de la nutrición enteral hipocalórica frente a la nutrición enteral estándar sobre los desenlaces clínicos en adultos críticamente enfermos: metanálisis de ensayos controlados, aleatorizados y con análisis secuencial

Objectives To compare the effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults, and to investigate the influence of protein intake upon the outcome effects of hypocaloric feeding. Design A meta-analysis of randomized controlled trials (RCTs) and trial sequential analysis (TSA) were carried out. Setting Intensive Care Unit (ICU). Patients Or participants Critically ill adults. Interventions Hypocaloric enteral feeding versus standard enteral feeding. Main variables of interest The primary outcomes were all-cause short-term mortality and the incidence of nosocomial infection. Results Eleven RCTs met the inclusion criteria; of these trials, two were judged as having low risk of bias. Compared with standard enteral feeding, hypocaloric enteral feeding had no benefits in terms of reducing short-term mortality, the incidence of nosocomial infection, or long-term mortality, though it had a positive impact upon the incidence of gastrointestinal intolerance. The TSA further confirmed these results. In turn, hypocaloric enteral feeding had no effects upon the incidence of bloodstream infection, pneumonia, hypoglycemia or the duration of mechanical ventilation, ICU stay, or in-hospital stay. The above results remained unchanged in the sub-analysis of trials with a low risk of bias, trials administering a similar dose of protein, or trials administering different doses of protein. Conclusions Compared with standard enteral feeding, hypocaloric enteral feeding was not associated with better clinical outcomes in critically ill adults, except for a lower risk of gastrointestinal intolerance. The difference in protein intake between groups might have no influence on the outcome effects of hypocaloric enteral feeding. High quality randomized controlled trials are needed to confirm this, however. (AU)

Objetivos Comparar el efecto de la nutrición enteral hipocalórica frente a la nutrición enteral estándar en adultos críticamente enfermos, así como investigar la influencia de la ingesta de proteínas sobre los efectos de la nutrición enteral hipocalórica. Diseño Metanálisis de ensayos controlados y aleatorizados y análisis secuencial de ensayos. Ámbito Unidad de Cuidados Intensivos. Pacientes Adultos críticamente enfermos. Intervenciones Nutrición enteral hipcalórica frente a nutrición enteral estándar. Variables de interés principales Los desenlaces principales fueron la mortalidad a corto plazo por cualquier causa y los episodios de infección nosocomial. Resultados Once ensayos controlados y aleatorizados cumplieron los criterios de inclusión y se consideró que dos de ellos presentaban un bajo riesgo de sesgo. En comparación con la nutrición enteral estándar, la nutrición enteral hipocalórica no presentó ningún riesgo en cuanto a la reducción de la mortalidad a corto plazo, los episodios de infección nosocomial ni la mortalidad a largo plazo, pero sí presentó un efecto beneficioso sobre los episodios de intolerancia gastrointestinal. El análisis secuencial de ensayos confirmó estos resultados. Por otra parte, la nutrición enteral hipocalórica no tuvo ningún efecto sobre los episodios de bacteriemia, neumonía o hipoglucemia, así como tampoco sobre la duración de la ventilación mecánica, de la estancia en la Unidad de Cuidados Intensivos ni del ingreso hospitalario. No se observó ningún cambio en estos resultados en el subanálisis de los ensayos con un bajo riesgo de sesgo, en los ensayos en los que se administró una dosis similar de proteínas ni en los ensayos en los que se administró una dosis diferente de proteínas. Conclusiones En comparación con la nutrición enteral estándar, la nutrición enteral hipocalórica no se asoció con unos mejores desenlaces en adultos críticamente enfermos, con la excepción de un menor riesgo de intolerancia gastrointestinal... (AU)

Evaluación y apoyo nutricional en el paciente pediátrico críticamente enfermo: Revisión de la literatura

RESUMEN Esta revisión se basa en la mejor evidencia actualmente disponible, y en ella se definen las directrices en relación con la evaluación y manejo nutricional en niños críticamente enfermos. Estas directrices incluyen, los criterios para la detección de la malnutrición, tanto por déficit o exceso, así como, se identifican las recomendaciones y consensos de expertos sobre la estimación energética y de macronutrientes, los cuales pueden ser determinantes en prevenir tanto la sobrealimentación como subalimentación. También se señalan las recomendaciones internacionales sobre el momento de inicio del soporte nutricional para que esta sea oportuna, efectiva y segura, eligiendo la vía de alimentación según condición clínica y tipo de patología en función de disminuir el riesgo de morbimortalidad de estos pacientes. A modo general, se sugiere intensificar la investigación científica, con el fin de disponer de mejor evidencia para diseñar protocolos clínicos internacionales y locales para el manejo nutricional del paciente pediátrico críticamente enfermo.

ABSTRACT This review is based on the best evidence currently available and defines the guidelines for the nutritional assessment and management of critically ill children. These guidelines include the criteria for detecting malnutrition, whether due to deficit or excess, as well as the recommendations and consensus of experts on the estimation of energy and macronutrients, which can be decisive in preventing both overfeeding and underfeeding. International recommendations on the time of initiation of nutritional support are also indicated so that it is timely, effective and safe. Choice of feeding route according to clinical condition and pathology type in order to reduce the risk of morbi-mortality of these patients are discussed. In general, an increase in scientific research is suggested, in order to have better evidence to design international and local clinical protocols for the nutritional management of critically ill pediatric patients.

[Effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis].

OBJECTIVES: To compare the effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults, and to investigate the influence of protein intake upon the outcome effects of hypocaloric feeding. DESIGN: A meta-analysis of randomized controlled trials (RCTs) and trial sequential analysis (TSA) were carried out. SETTING: Intensive Care Unit (ICU). PATIENTS: Or participants Critically ill adults. INTERVENTIONS: Hypocaloric enteral feeding versus standard enteral feeding. MAIN VARIABLES OF INTEREST: The primary outcomes were all-cause short-term mortality and the incidence of nosocomial infection. RESULTS: Eleven RCTs met the inclusion criteria; of these trials, two were judged as having low risk of bias. Compared with standard enteral feeding, hypocaloric enteral feeding had no benefits in terms of reducing short-term mortality, the incidence of nosocomial infection, or long-term mortality, though it had a positive impact upon the incidence of gastrointestinal intolerance. The TSA further confirmed these results. In turn, hypocaloric enteral feeding had no effects upon the incidence of bloodstream infection, pneumonia, hypoglycemia or the duration of mechanical ventilation, ICU stay, or in-hospital stay. The above results remained unchanged in the sub-analysis of trials with a low risk of bias, trials administering a similar dose of protein, or trials administering different doses of protein. CONCLUSIONS: Compared with standard enteral feeding, hypocaloric enteral feeding was not associated with better clinical outcomes in critically ill adults, except for a lower risk of gastrointestinal intolerance. The difference in protein intake between groups might have no influence on the outcome effects of hypocaloric enteral feeding. High quality randomized controlled trials are needed to confirm this, however.

Association between storage age of transfused red blood cells and clinical outcomes in critically ill adults: A meta-analysis of randomized controlled trials.

OBJECTIVES: A meta-analysis was performed to assesses the effect of storage age of transfused red blood cells (RBCs) upon clinical outcomes in critically ill adults. METHODS: A comprehensive search was conducted in the PubMed, OVID, Web of Science and Cochrane databases for randomized controlled trials (RCTs) comparing the transfusion of fresher versus older RBCs in critically ill adults from database inception to December 2017. The primary endpoint was short-term mortality, and the secondary endpoints were the duration of intensive care unit (ICU) and hospital stay. The pooled odds ratios (OR) and mean differences (MD) were calculated using Stata/SE 11.0. RESULTS: A total of six RCTs were identified, of which four were multicenter studies, while two were single-center trials. The pooled results indicated that the transfusion of fresher RBCs was not associated to a decrease in short-term mortality compared with the transfusion of older RBCs (random-effects OR=1.04, 95% confidence interval (CI): 0.96-1.13, P=0.312; I2=0.0%; six trials; 18240 patients), regardless of whether the studies were of a multi-center (random-effects OR=1.04, 95% CI: 0.96-1.13, P=0.292; I2=0.0%) or single-center nature (random-effects OR=1.16, 95% CI: 0.28-4.71, P=0.839; I2=56.7%), or with low risk of bias (random-effects OR=1.04, 95% CI: 0.94-1.16, P=0.445; I2=0.0%). In addition, the transfusion of fresher RBCs did not reduce the geometric mean duration of ICU stay (1.0% increase in geometric mean, 95% CI: -3.0 to 5.1%, P=0.638; I2=81.5%; four trials; 7550 patients) or the geometric mean duration of hospital stay (0.0% increase in geometric mean, 95% CI: -3.9 to 4.1%, P=0.957; I2=7.4%; four trials; 7550 patients) compared with the transfusion of older RBCs. CONCLUSIONS: The transfusion of fresher RBCs compared with older RBCs was not associated to better clinical outcomes in critically ill adults.

APACHE II score for critically ill patients with a solid tumor: A reclassification study. / Escala APACHE II para pacientes críticos con cáncer sólido. Estudio de reclasificación.

OBJECTIVE: To improve the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) II model for predicting hospital mortality in critically ill cancer patients. MATERIALS AND METHODS: This was a prospective cohort study of 522 patients admitted to ICU with a solid tumor. We developed the "APACHE II score for critically ill patients with a solid tumor" (APACHE IICCP score), in which typical variables of critically ill cancer patients were added to general APACHE II score. Calibration and discrimination were evaluated by Hosmer-Lemeshow test (H-L) and area under receiver operating characteristic curve (AROC), respectively. The improvement in predicting hospital mortality with the new model was assessed using a reclassification analysis by integrated discrimination improvement (IDI), net reclassification improvement (NRI; cut-off point of 20% in risk of death) and quantitative NRI (qNRI). RESULTS: The hospital mortality rate was 13%. Discrimination was superior for APACHE IICCP score (AROC=0.91 [95% CI 0.87-0.94; P<.0001]) compared to general APACHE II score (AROC=0.62 [95% CI 0.54-0.70; P=.002]). Calibration was better using APACHE IICCP score (H-L; P=.267 vs. P=.001). In reclassification analysis, an improved mortality prediction was observed with APACHE IICCP score (IDI=0.2994 [P<.0001]; total qNRI=134.3% [95% CI 108.8-159.8%; P<.0001]; total NRI=41.5% [95% CI 23.7-59.3%; P<.0001]). CONCLUSIONS: The performance of APACHE IICCP score was superior to that observed for general APACHE II score in predicting mortality in critically ill patients with a solid tumor. Other studies validating this new predictive model are required.

Desarrollo de la escala modificada simplificada de riesgo nutricional (NUTRIC) en el paciente crítico / Development of a modified, simplified nutritional risk score (NUTRIC) in critically ill patients / Desenvolvimento da escala modificada simplificada de risco nutricional (nutric) no paciente em estado crítico

Resumen: Introducción: La escala NUTRIC es una de las herramientas propuestas para la evaluación del riesgo nutricional en pacientes críticamente enfermos. Contiene dos índices pronósticos de gravedad: Acute Physiology and Chronic Evaluation II (APACHE II) y la puntuación Sequential Organ Failure Assessment (SOFA), lo que genera un alto riesgo de colinealidad. Métodos: En el presente estudio se pretende eliminar la colinealidad otorgada por el APACHE II y la puntuación SOFA utilizados en la puntuación NUTRIC, simplificando dicha herramienta. Se realizaron dos escalas alternas: NUTRIC modificado con un ajuste por APACHE II, eliminando el puntaje por APACHE II y obteniendo un coeficiente de ajuste mediante regresión lineal, y NUTRIC sin APACHE II, restando los puntos otorgados por éste. Posteriormente, se hicieron curvas ROC con el fin de determinar el desempeño de ambas escalas en detectar riesgo nutricional. Resultados: Fueron incluidos 225 pacientes a lo largo del estudio. La regresión lineal en contra del NUTRIC convencional mostró para el NUTRIC sin APACHE II un coeficiente de Pearson = 0.918, r2 = 0.843, p < 0.05, m = 1.368, b = 0, y para el NUTRIC modificado un coeficiente de Pearson = 0.918, r2 = 0.843, p < 0.05. Ambas curvas ROC resultaron con un área bajo la curva de 0.95, p < 0.05. Conclusión: Al eliminar el APACHE II de la escala NUTRIC se evita la colinealidad, con lo que se obtienen dos puntos corte de tres y cinco para la detección de bajo riesgo (sensibilidad = 99%) y alto riesgo (especificidad = 99%), respectivamente, y un puntaje de cuatro para realizar una evaluación especializada.

Abstract: Introduction: The NUTRIC score is one of the tools proposed for nutritional risk assessment in critically ill patients. This score uses two severity scores: Acute Physiology and Chronic Evaluation II (APACHE II) and Sequential Organ Failure Assessment score (SOFA), which generates a high risk for collinearity. Methods: The goal of the present study is to eliminate the collinearity between the APACHE II and the SOFA used in the NUTRIC score, optimizing such tool. Two alternative scales were developed: modified NUTRIC with an adjustment for APACHE II, by eliminating the points given by the APACHE II and obtaining an adjustment coefficient through linear regression, and the NUTRIC without APACHE II. ROC curves were built to determine the performance of both scores for detecting nutritional risk. Results: Two hundred twenty five patients where included in the study. Linear regression between the conventional NUTRIC score and the NUTRIC without APACHE II showed a Pearson coefficient of 0.918, r(2) = 0.843, p < 0.05, m = 1.368, b = 0, and the modified NUTRIC, a Pearson coefficient of 0.918, r(2) = 0.843, p < 0.05. Both ROC curves resulted in equal areas under the curve of 0.951, p < 0.05. Conclusion: By eliminating the APACHE II of the NUTRIC score, collinearity is avoided, obtaining two cutoff points of 3 and 5 to detect low risk (sensibility = 99%) and high risk (specificity = 99%), respectively, and a score of 4 to perform an advanced assessment, optimizing its time.

Resumo: Introdução: O escore NUTRIC é uma das ferramentas propostas para a avaliação do risco nutricional em pacientes em estado crítico. Esta escala contém dois índices de prognóstico de gravidade: Acute Physiology and Chronic Evaluation II (APACHE II) e Sequential Organ Failure Assessment score (SOFA), gerando um elevado risco de colinearidade. Métodos: Neste estudo pretendemos eliminar a colinearidade outorgada pelo APACHE II e SOFA escore utilizados no NUTRIC escore, simplificando essa ferramenta. Realizaram-se duas escalas alternativas: NUTRIC modificado com um ajuste pelo APACHE II, eliminando a pontuação por APACHE II e obtendo um coeficiente de ajuste por regressão linear e NUTRIC sem APACHE II, subtraindo os pontos atribuídos pelo APACHE II. Posteriormente realizaram-se curvas ROC com o fim de determinar o desempenho de ambas escalas em detectar o risco nutricional. Resultados: 225 pacientes foram incluídos ao longo do estudo. A regressão linear em contra da NUTRIC convencional mostrou para NUTRIC sem APACHE II um coeficiente de Pearson = 0.918, r 2 = 0.843, p < 0.05, m = 1.368, b = 0 e para NUTRIC modificado um coeficiente de Pearson = 0.918, um r 2 = 0.843, p < 0.05. Ambas curvas ROC resultaram com uma área sob a curva de 0.95, p < 0.05. Conclusão: Ao eliminar o APACHE II da escala NUTRIC evitamos a colinearidade obtendo dois pontos de corte de 3 e 5 para a detecção de baixo risco (sensibilidade = 99%) e de alto risco (especificidade = 99%), respectivamente, e uma pontuação de 4 para uma avaliação especializada.

El niño con Síndrome de Down en la Unidad de Cuidados Intensivos / Down Syndrome child in the Intensive care unit

El síndrome de Down es la alteración cromosómica más frecuente en los recién nacidos, con una alta incidencia en Chile. Esta condición presenta aspectos fisiológicos únicos, los cuales pueden afectar al niño durante su estadía en una Unidad de Cuidados Intensivos, posterior al período neonatal. En esta revisión abordamos aspectos actuales de la patología respiratoria, cardiovascular, infecciosa y neurológica, así como también consideraciones anestésicas y de analgesia postoperatoria, destete de la ventilación mecánica, inestabilidad columna cervical y pronóstico del niño críticamente enfermo portador de síndrome de Down. La evaluación de todas estas condiciones debe ser realizada cuando el paciente es ingresado a la Unidad de Cuidados Intensivos. El objetivo de la presente actualización es profundizar el conocimiento del diagnóstico y tratamiento de las potenciales complicaciones del niño con síndrome de Down durante su estadía en la unidad de paciente crítico.

Down syndrome is the most common chromosomal abnormality in newborns, with a high incidence in Chile. This condition presents unique physiological aspects that should be known, which can affect the child during their stay in an Intensive Care Unit, beyond the neonatal period This review is focused on the respiratory, cardiovascular, infectious and neurological disorders. Anesthetic management and postoperative analgesia considerations, weaning from mechanical ventilation, cervical spine instability and prognosis of the critically ill child with Down syndrome are also analyzed. The evaluation of these conditions should be performed when the patient is admitted to the intensive care unit. The purpose of this update is to update the knowledge of the diagnosis and treatment of potential complications of children with Down syndrome during their stay in the unit of critical patient.

Perfil de seguridad de bemiparina como tromboprofilaxis en pacientes crítico / Safety profile of bemiparin thromboprofilaxis in critically III patients / Perfil de segurança da bemiparina como tromboprofilaxia em pacientes en estado crítico

Resumen: Introducción: La enfermedad tromboembólica es una causa prevenible de mortalidad en pacientes críticamente enfermos. La estrategia de tromboprofilaxis más utilizada es el uso de heparinas de bajo peso molecular; sin embargo, no se conoce cuál es superior. La bemiparina presenta características farmacológicas favorables. Objetivo: Evaluar el perfil de seguridad de la tromboprofilaxis con bemiparina en pacientes críticos. Material y métodos: Se trata de un estudio retrospectivo y observacional. Se incluyeron pacientes hospitalizados en la Unidad de Cuidados Intensivos de Adultos entre diciembre de 2013 y junio de 2015 que recibieron bemiparina. Se evaluó la presencia de sangrado mayor, trombocitopenia y correlaciones entre la dosis administrada y la presencia de eventos adversos. Resultados: 111 pacientes críticos recibieron bemiparina como tromboprofilaxis. No hubo episodios de enfermedad tromboembólica. Seis punto tres por ciento de los pacientes presentaron sangrado mayor durante su estancia. La incidencia de trombocitopenia severa fue de 1.8%, 8.6% presentó descenso en la cuenta plaquetaria sugerente de trombocitopenia inducida por heparina; no obstante, no se documentó ningún caso. Los efectos adversos no se asociaron a mayores dosis de bemiparina. Conclusiones: La seguridad de la tromboprofilaxis con bemiparina es comparable con el resto de las heparinas de bajo peso molecular (HBPM) en pacientes críticamente enfermos.

Abstract: Introduction: Venous thromboembolism is a preventable cause of death in critically ill patients. The most common thromboprophylaxis strategy is the use of low molecular weight heparins, however it is not known which is superior. Bemiparin shows a favorable pharmacologic profile. Objective: Evaluate the safety profile of bemiparin thromboprophylaxis in the critically ill. Materials and methods: This retrospective observational trail was carried out in an adult intensive care unit. Patients hospitalized between December 2013 and June 2015 receiving bemiparin throboprophylaxis were included. The presence of major bleeding, thrombocytopenia and the correlation between dose and adverse events was noted. Results: 111 critically ill patients received bemiparin thromboprophylaxis No episodes of venous thromboembolism were recorded. 6.3% of patients had a major bleeding episode during their intensive care unit stay. The incidence of severe thrombocytopenia was 1.8%, while 8.6% of patients had a platelet count decrease typical of heparin induced thrombocytopenia, no cases were recorded. Adverse events were not associated with bemiparin dose. Conclusions: The safety of bemiparin thromboprofilaxis is similar to that of other Low Molecular Weight Heparins (LMWH) in critically ill patients.

Resumo: Antecedentes: A doença tromboembólica é uma causa evitável de morte em pacientes em estado crítico. A estratégia tromboprofiláxica mais utilizada é o uso de heparinas de baixo peso molecular, no entanto, não é conhecido qual é superior. A bemiparina apresenta características farmacológicas favoráveis. Objetivo: Avaliar o perfil de segurança da tromboprofilaxia com bemiparina em pacientes em estado crítico. Material e métodos: Estudo retrospectivo observacional na unidade de terapia intensiva de adultos. Foram incluídos pacientes hospitalizados na unidade de terapia intensiva que receberam bemiparina entre dezembro de 2013 e junho 2015. Avaliou-se a presença de hemorragia grave, trombocitopenia e correlações entre doses administrada e a presença de eventos adversos. Resultados: 111 pacientes em estado crítico receberam bemiparina como tromboprofilaxia. Não houve episódios de tromboembolismo. 6.3% dos pacientes apresentaram sangramento maior durante a sua estadia. A incidência de trombocitopenia grave foi de 1.8%, 8.6% apresentaram uma diminuição na contagem de plaquetas sugestivos de trombocitopenia induzida pela heparina, porém não se documentou nenhum caso. Os efeitos adversos não se associaram com a doses mais elevadas de bemiparina. Conclusão: A segurança de tromboprofilaxia bemiparina é comparável com o resto do Heparina de baixo peso molecular (HBPM) em pacientes em estado critico.

Antibiotic dose optimization in critically ill patients.

The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.

Caracterización de las intervenciones de enfermería ante el dolor físico vivenciado en seres humanos críticamente enfermos en la unidad de cuidados intensivos / aharacterization of nursing interventions to the physical pain experienced in humans critically ill in intensive care UNI

Esta investigación busca caracterizar las intervenciones de los profesionales de enfermería ante el dolor físico vivenciado por pacientes de la Unidad de Cuidado Intensivo Adulto del Hospital San Ignacio, de la ciudad de Bogotá. Estudio de enfoque cuantitativo, con diseño descriptivo e interpretativo, empleando como técnica la recolección de información a través de una lista de chequeo, que aborda tres momentos del manejo del dolor: valoración, intervención y evaluación, sustentada en los supuestos teóricos de la Teoría de Rango Medio Síntomas Desagradables. Se ejecutaron 148 listas de chequeo, de las cuales 97 fueron las que cumplieron los criterios para el análisis de cada ítem, evidenciándose la importancia de caracterizar las intervenciones del profesional de enfermería como un proceso necesario y pertinente para proporcionar una estancia de calidad al paciente, puesto que el dolor genera múltiples alteraciones en el paciente que requiere una valoración, intervención y evaluación integral, dentro de un contexto individualizado, personalizado y humanizado.

This research seeks to characterize the activities of nurses to the physical pain experienced by patients in the Adult Intensive Care Unit of the San Ignacio Hospital in Bogota. Quantitative approach study with descriptive and interpretative design, using the technique of gathering information through a checklist that addresses three moments of pain management: assessment, intervention and evaluation, based on the theoretical assumptions of the theory Midrange disagreeable symptoms. 148 checklists were implemented, of which 97 were those who met the criteria for the analysis of each item, showing the importance of characterizing the interventions of the nurse as a necessary and relevant process to provide quality patient stay, Since pain generates multiple alterations in the patient requiring an assessment, comprehensive assessment and intervention within an individualized, personalized and humanized context.