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Resumen Objetivo Pocos estudios han evaluado el impacto en el diagnostico y tratamiento de la ecocardiografia transtoracica basica en los pacientes postoperados de cirugia cardiaca. El objetivo de nuestro estudio fue valorar el impacto de la ecocardiografia transtoracica basica en el manejo diagnostico y terapeutico de estos pacientes. Diseno Durante 18 meses se estudiaron prospectivamente todos los pacientes postoperados de cirugia cardiaca que ingresaron en el Servicio de Medicina Intensiva de un hospital universitario. Se realizo una valoracion clinica a todos ellos para establecer un diagnostico y un tratamiento inicial. Se realizo una ecocardiografia transtoracica basica para valoracion diagnostica, que se comparo con la valoracion clinica. En caso de discrepancia, se valoro cambiar el tratamiento en funcion a la ecocardiografia y se evaluo la respuesta terapeutica. Se realizo un analisis descriptivo de los hallazgos. Resultados Se incluyeron 136 pacientes y se realizaron 203 ecocardiografias. La ecocardiografia transtoracica diferia del diagnostico inicial en 101 (49,8%) ecocardiografias. En 56 de estas (55,44%) se obtuvo un diagnostico alternativo, lo que comporto un cambio en el tratamiento en 30 pacientes (53,6%). Encontramos mejoria clinica significativa en 26 de estos pacientes (86,76%) en los siguientes 30-60 min. Conclusiones La ecocardiografia transtoracica basica es util en el manejo diagnostico y terapeutico de los pacientes postoperados de cirugia cardiaca. En la mitad de las ecocardiografias realizadas no se pudo confirmar el diagnostico clinico. En la mayoria de los pacientes en que observamos cambio en el diagnostico debido a la ecocardiografia, se observo mejoria clinica tras el cambio de tratamiento.

Resumen La sepsis es una entidad sindromica de elevada prevalencia y mortalidad. Su manejo esta estandarizado y tiene una eficacia dependiente del tiempo. Sin embargo, el manejo de los pacientes con sepsis es complejo. La heterogeneidad de las formas de presentacion puede dificultar su deteccion y manejo, asi como las diferencias en formacion, competencias o disponibilidad de recursos sanitarios. La Comision Asesora para la Atencion al PAciente con Sepsis (CAAPAS), formada por 7 sociedades cientificas, el Sistema de Emergencias Medicas (SEM) y el Servei Catala de la Salut (CatSalut), han desarrollado en Catalunya el Codigo Sepsis Interhospitalario (CSI). El objetivo general del CSI es facilitar la deteccion precoz, la atencion inicial y la coordinacion interhospitalaria para optimizar el tratamiento de los pacientes con sepsis o shock septico en formato codigo de riesgo vital, de forma homogenea a lo largo de todo el territorio catalan.

Objetivo: Estimar la prevalencia de fragilidad en pacientes ingresados en cuidados intensivos(UCI) y su impacto sobre la mortalidad intra UCI, al mes y a los 6 meses.Dise ̃no: Estudio de cohorte prospectiva.Ámbito: UCI polivalentes espa ̃nolas.Intervención: Ninguna.Pacientes y métodos: Pacientes ≥ 65 a ̃nos ingresados en UCI > 24 horas. Se recogieron las varia-bles al ingreso y la situación basal por teléfono al mes y a los 6 meses del alta de UCI.Variables de interés principal: Edad, sexo, fragilidad (escala FRAIL), situación basal (Barthel,Lawton, Clinical Dementia Rating y Nutric Score), días de ventilación mecánica (VM), escalasde gravedad (APACHE II y SOFA), mortalidad UCI, al mes y a los 6 meses del alta.Resultados: Ciento treinta y dos pacientes, 46 frágiles (34,9%). Pacientes frágiles vs. no frágiles:78,8 ± 7,2 vs. 78,6 ± 6,4 a ̃nos (p = 0,43), varones 43,8% vs. 56,3% (p = 0,10), SOFA 4,7 ± 2,9 vs.4,6 ± 2,9 (p = 0,75), VM 33.3% vs. 66,7% (p = 0,75), días de VM 5,6 ± 15 vs. 4,3 ± 8,1 (p = 0,57),mortalidad UCI 13% versus 6% (p = 0,14), mortalidad al mes 24% versus 8% (p = 0,01), mortalidad6 meses 32% versus 15% (p = 0,03). La fragilidad se asocia con la mortalidad al mes (OR = 3,5;p 24 hours. Variableswere registered upon admission, and functional status was assessed by telephone calls 1 and6 months after discharge from the ICU.Main study variables: Age, gender, frailty (FRAIL scale), functional status (Barthel, Lawton,Clinical Dementia Rating and NUTRIC score), days of mechanical ventilation (MV), functionalscore (APACHE II and SOFA), ICU mortality, and mortality 1 and 6 months after ICU discharge.Results: A total of 132 patients were evaluated, of which 46 were frail (34.9%). Age of the frailversus non-frail patients: 78.8 ± 7.2 and 78.6 ± 6.4 years, respectively (P = .43); male gender:43.8% versus 56.3% (P = .10); SOFA score: 4.7 ± 2.9 versus 4.6 ± 2.9 (P = .75); MV: 33.3% versus66.7% (P = .75); days of MV: 5.6 ± 15 versus 4.3 ± 8.1 (P = .57); ICU mortality 13% versus 6%(P = .14), mortality at 1 month 24% versus 8% (P = .01), mortality 6 months 32% versus 15% (P= .03). Frailty is associated with mortality at one month (OR = 3.5, P

Objective To estimate the prevalence of frailty in patients admitted to the Intensive Care Unit (ICU) and its impact upon ICU mortality at 1 and 6 months. Design A prospective observational cohort study was carried out. Setting Spanish ICU. Intervention None. Patients and methods Patients ≥ 65 years of age admitted to the ICU for >24 h. Variables were registered upon admission, and functional status was assessed by telephone calls 1 and 6 months after discharge from the ICU. Main study variables Age, gender, frailty (FRAIL scale), functional status (Barthel, Lawton, Clinical Dementia Rating and NUTRIC score), days of mechanical ventilation (MV), functional score (APACHE II and SOFA), ICU mortality, and mortality 1 and 6 months after ICU discharge. Results A total of 132 patients were evaluated, of which 46 were frail (34.9%). Age of the frail versus non-frail patients: 78.8 ± 7.2 and 78.6 ± 6.4 years, respectively ( P = .43); male gender: 43.8% versus 56.3% ( P = .10); SOFA score: 4.7 ± 2.9 versus 4.6 ± 2.9 ( P = .75); MV: 33.3% versus 66.7% ( P = .75); days of MV: 5.6 ± 15 versus 4.3 ± 8.1 ( P = .57); ICU mortality 13% versus 6% ( P = .14), mortality at 1 month 24% versus 8% ( P = .01), mortality 6 months 32% versus 15% ( P = .03). Frailty is associated with mortality at one month (OR = 3.5, P P Conclusions Frailty was present in 35% of the patients admitted to the ICU, and was associated with mortality.

Previous studies unveiled a relation between COVID-19 severity and obesity. The aims of this multicenter retrospective cohort study were to disentangle the association of body mass index (BMI) and associated metabolic risk factors, with pneumonia outcomes in critically ill patients with COVID-19, and explore the impact of age and sex on this relationship. Participants were COVID-19 patients admitted in intensive care in 21 centers in Europe, Israel, and USA, between 02/19/2020 and 05/19/2020. The exposure of interest was BMI. The primary and secondary outcomes were the need for invasive mechanical ventilation (IMV), and 28-day mortality. The covariates were age, sex, and diabetes, hypertension, hyperlipidemia, and current smoking. We enrolled 1,461 patients (median age 64 years (Interquartile range (IQR), 40.9-72.0); 73.2% males; median BMI 28.1 kg/m2 (IQR, 25.4-32.3); 1,080 patients (73.9%) required IMV and the 28-day mortality rate was 36.1% (95% confidence intervals (CI), 33.0-39.5). Adjusted mixed logistic regression model showed a significant relation between BMI and IMV: odds ratio 1.27 (95% CI, 1.12-1.45) per 5 kg/m2 in the whole cohort, and 1.65 (95% CI, 0.97-2.79) per 5 kg/m2 in females under 50 years. Adjusted Cox proportional hazards regression model showed a significant association between BMI and mortality, which was only increased in obesity class III (≥40 kg/m2) (Hazard Ratio 1.68 (95% CI 1.06-2.64). In conclusion, we observed in critically ill COVID-19 patients, a linear association between BMI and the need for IMV, independent of other metabolic risk factors, and more pronounced in younger females, and a non-linear association between BMI and mortality risk. Trial Registration: ClinicalTrials.gov Identifier: NCT04391738 Funding Statement: No specific funding. Declaration of Interests:The authors declared no conflict of interest. Ethics Approval Statement: The study complied with standard operating procedures in place, in accordance with the European Data Protection Directive (95/46/EC) and, upon its entry into force, Regulation (EU) 2016/679 (also referred to as the General Data Protection Regulation (GDPR)), and French CNIL frameworks n° MR004 regarding the processing of personal data in clinical studies. The institutional review board from other centers in USA and Israel approved the retrospective case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent.

Objective To analyze the evolution of sepsis-related mortality in Spanish Intensive Care Units (ICUs) following introduction of the Surviving Sepsis Campaign (SSC) guidelines and the relationship with sepsis process-of-care. Design A prospective cohort study was carried out, with the inclusion of all consecutive patients presenting severe sepsis or septic shock admitted to 41 Spanish ICUs during two time periods: 2005 (Edusepsis study pre-intervention group) and 2011 (ABISS-Edusepsis study pre-intervention group). Scope Patients with severe sepsis or septic shock admitted to Spanish ICUs. Patients All ICU admissions from the emergency department or wards and all ICU patients with a diagnosis of severe sepsis or septic shock. A total of 1348 patients were included: 630 in the 2005 group and 718 in the 2011 group. Intervention None. Primary endpoints ICU mortality, 28-day mortality and Hospital mortality, hospital length of stay, ICU length of stay and compliance with the resuscitation bundle. Results Compliance with the resuscitation bundle was significantly greater in the 2011 group (5.7% vs. 9.9%; p = 0.005), and was associated to lower mortality (OR 0.602 [0.365–0.994]; p = 0.048). The 2011 group had lower absolute in-hospital mortality (44.0% vs. 32.6%; p = 0.01), 28-day mortality (36.5% vs. 23.0%; p = 0.01), and adjusted mortality (OR 0.64 [0.49–0.83], p = 0.001). Conclusions Mortality related to severe sepsis or septic shock in Spain decreased between two patient cohorts in 2005 and 2011, and was attributable to earliness and improvement in sepsis care.

Background Continuous aspiration of subglottic secretions is effective in preventing ventilator-associated pneumonia, but it involves a risk of mucosal damage. The main objective of our study was to determine the incidence of airway complications related to continuous aspiration of subglottic secretions. Methods In consecutive adult patients with continuous aspiration of subglottic secretions, we prospectively recorded clinical airway complications during the period after extubation. A multidetector computed tomography of the neck was performed during the period of 5 days following extubation to classify subglottic and tracheal lesions as mucosal thickening, cartilage thickening or deep ulceration. Results In the 86 patients included in the study, 6 (6.9%) had transient dyspnea, 7 (8.1%) had upper airway obstruction and 18 (20.9%) had dysphonia at extubation. Univariate analysis identified more attempts required for intubation (2.3 ± 1.1 vs. 1.2 ± 0.5; p = 0.001), difficult intubation (71.4 vs. 10.1%, p = 0.001) and Cormack score III–IV (71.4 vs. 8.8%; p

Resumen Objetivo Evaluacion de la eficiencia asistencial en UCI basado en un modelo predictivo. Diseno Estudio observacional prospectivo de cohortes. Ambito 17 UCI espanolas polivalentes Pacientes Se valoro una cohorte A de 1.956 pacientes. Posteriormente y a intervalos de 6 anos se recogieron las cohortes B (453), C (2.567) y D (711) en una de las UCI estudiadas. Metodo Se evaluaron 5 indices de gravedad y mortalidad y con ellos los cocientes estandarizados (observada/calculada) de mortalidad en todas las cohortes. Se utilizo el analisis de regresion multiple para el desarrollo del modelo de prediccion de estancia. Mediante este modelo se analizaron los cocientes estandarizados de estancia en cada cohorte. Durante estos periodos se analizaron los cambios organizativos realizados en la UCI estudiada. Resultados La probabilidad calculada de muerte intrahospitalaria fue del 15,4% y a las 24 h del ingreso fue del 14,7% en la cohorte A, en tanto que la mortalidad observada fue del 20,3%. Se elaboro un modelo de regresion lineal multiple que fue utilizado para calcular la mortalidad y estancia estandarizadas para las cohortes B, C y D, que fueron de 1,8 y 1,2 (cohorte B), 0,7 y 1,07 (cohorte C), y 0,63 y 1,07 (cohorte D), respectivamente. La progresiva mejoria de resultados se intenta vincular con cambios organizativos y estructurales. Conclusiones El modelo desarrollado fue un buen predictor de la estancia en UCI, lo que, junto al analisis de mortalidad puede constituir una buena alternativa en la evaluacion de calidad asistencial.

Flexible bronchoscopy (FB) has been of great help in the management of critically ill patients. Its safety and usefulness in the hands of experienced professionals, with the required measures of caution, has resulted in the increasingly widespread use of the technique even in unstable critical patients subjected to mechanical ventilation and with high oxygen demands. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and standards of quality in the use of FB among all specialists in Intensive Care Medicine. Through an expert committee, the SEMICYUC has established the objective of accrediting such training, with the preparation of a curriculum and definition of those Units qualified for providing training in the different techniques and levels. The accreditation process seeks to stimulate good learning practice and quality in training. Both specialists in Intensive Care Medicine and other specialists, and the patients, will benefit from the commitment and control afforded by such accreditation, and from the learning and training which the mentioned process entails.

Resumen Objetivos Analizar la evolucion de los pacientes con insuficiencia renal aguda tratados con terapia de reemplazo renal (TRR) y determinar los factores de riesgo asociados a mortalidad y recuperacion de la funcion renal. Diseno Estudio prospectivo y observacional en pacientes criticos. Ambito Unidad de Cuidados Intensivos (UCI) polivalente del Hospital de Sabadell. Pacientes Inclusion de los pacientes con insuficiencia renal que precisaron TRR en nuestra unidad. Principales variables de interes Registro de variables epidemiologicas, de gravedad (APACHE II) asi como el tipo y duracion de la TRR, mortalidad y recuperacion de la funcion renal al alta de UCI. El periodo de estudio comprende 10 anos, repartiendo la muestra en 2 periodos: inicial (2000-2004) y reciente (2005-2009). Analisis estadistico comparativo de ambos periodos y analisis de regresion logistica multiple para determinar factores de riesgo de mortalidad y de recuperacion de funcion renal. Resultados Analisis de 304 pacientes. Principal causa de ingreso la sepsis (61%), siendo el foco respiratorio y el abdominal los mas frecuentes. El origen comunitario de la insuficiencia renal y la tecnica convectiva se incrementaron en el periodo reciente. Destaca un descenso de dias de terapia (19,7 a 12,3; p = 0,015). La mortalidad global en UCI fue de 52,3%, siendo la principal causa el fallo multiorganico, objetivando un descenso entre ambos periodos (61,9 a 45,5%; p = 0,003). Los factores relacionados con la mortalidad fueron la creatinina al ingreso (odds ratio [OR] 0,77; intervalo de confianza del 95% [IC95%] 0,61-0,97) y el tratamiento solo con HDI (OR 0,37; IC95% 0,16-0,87). De los supervivientes, al alta de UCI, en el periodo reciente destaca un aumento de los pacientes que quedan con dependencia de HD (10,4 versus 26,8%). Los factores relacionados con la recuperacion de la funcion renal fueron la creatinina al ingreso (OR 1,98; IC95% 1,12-3,48), la insuficiencia renal aguda versus la cronica agudizada (OR 0,11; IC95% 0,04-0,34) y el tratamiento con tecnicas continuas (OR 0,18; IC95% 0,03-0,85). Conclusiones La mortalidad de los pacientes criticos tratados con TRR ha mejorado en los ultimos anos.

Objectives To analyze the evolution of patients subjected to renal replacement therapy (RRT), and to determine risk factors associated with mortality and the recovery of renal function. Design A prospective, observational study of critically-ill patients. Setting Clinical–surgical Intensive Care Unit (ICU) of Sabadell Hospital (Spain). Patients Inclusion of all patients treated in our unit due to acute renal failure (ARF) requiring RRT. Primary variables of interest We recorded epidemiological data, severity using the APACHE II score, days of the technique, ICU mortality, and renal function recovery. The study period was divided into 2 parts: part 1 (2000–2004) and part 2 (2005–2009). The 2 periods were compared using the Student's t-test for continuous variables and the chi-squared test for categorical variables. Multiple regression analysis was performed to determine the risk factors for mortality and recovery of renal function. Results A total of 304 patients were treated. Sepsis was the main etiology of ARF (61%), involving principally respiratory and abdominal foci. In the second period the convective technique and community-acquired ARF were far more prevalent than in the first period. There were fewer days of therapy in the second period (19.7 versus 12.3 days; p = .015). Total ICU mortality was 52.3%, with a decrease in the last period (61.9–45.5%: p = .003). The risk factors associated with mortality were creatinine upon admission (odds ratio [OR] 0.77; 95% confidence interval [95%CI] 0.61–0.97) and treatment with IHD alone (OR 0.37, 95%CI 0.16–0.87). Survivors had normal renal function at ICU discharge in 56.7% of the cases in the second period, vs in 72.9% in the first period, with more patients subjected to IHD in the second period (10.4% versus 26.8%). The factors related to the recovery of renal function were creatinine upon admission (OR 1.98, 95%CI 1.12–3.48), acute renal failure (OR 0.11, 95%CI 0.04–0.34) and treatment with continuous techniques (OR 0.18, 95%CI 0.03–0.85). Conclusions Mortality among critically-ill patients subjected to RRT has improved in recent years.

The acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are part of a devastating syndrome characterized by acute onset, hypoxemia and bilateral infiltrates on chest radiography. ALI/ARDS is the response of the lung to a local or systemic insult, resulting in local inflammation and coagulation disorders, which lead to increased inflammatory pulmonary edema. ARDS is a major cause of morbidity, death, and expense in intensive care units. ALI and ARDS are associated with increased procoagulant and reduced fibrinolytic activities, mainly in alveoli and in interstitial spaces in the lung. Fibrin deposition, which is the hallmark of early-phase ALI, stimulates fibroblast aggregation and collagen secretion, participating in the constitution of pulmonary fibrosis. Despite the significant progress in the understanding of the disease made over the past 10 years, the only clinical intervention found to have a significant impact on mortality in ARDS is the use of low tidal volume ventilation. In se...

La lesión pulmonar aguda y, en su forma más grave, el síndrome de distrés respiratorio agudo, tiene una alta morbimortalidad y se caracteriza por un inicio brusco, hipoxemia e infiltrados bilaterales en la radiografía de tórax con ausencia de signos de insuficiencia cardiaca. En la fisiopatología de la lesión pulmonar aguda participa, junto a la activación de la inflamación, una alteración del sistema de la coagulación. Las alteraciones del sistema de la coagulación presentes en la lesión pulmonar aguda incluyen un aumento de la actividad procoagulante, así como un descenso de la actividad fibrinolítica, tanto en el espacio alveolar como en el intersticio pulmonar. Los depósitos de fibrina, que son el marcador inicial de la fase precoz de la lesión pulmonar aguda, estimulan la agregación de fibroblastos y la subsiguiente secreción de colágeno que conduce a la fibrosis pulmonar. El único tratamiento que ha demostrado tener un impacto significativo sobre la mortalidad en la lesión pulmonar aguda/síndrome de distrés respiratorio agudo, a pesar de los avances sobre el conocimiento de la enfermedad en los últimos 10 años, es el uso de ventilación protectora con volumen corriente bajo. En la sepsis grave donde también participa la coagulación, sólo el tratamiento con proteína C activada ha mostrado una reducción de la mortalidad junto con una mejoría de la disfunción respiratoria y descenso en los días de ventilación mecánica. En el futuro, para determinar el papel de los anticoagulantes en el tratamiento de la lesión pulmonar aguda/síndrome de distrés respiratorio agudo, los próximos estudios deberían considerar el potencial beneficio de los anticoagulantes aplicados a nivel sistémico o local pulmonar.

Sepsis is the response of the host to an infection that produces lesions in its own organs and tissues. Despite the great advances in modern medicine, including vaccines, antibiotics and intensive care, it is still the primary cause of death due to infection. Sepsis may result in shock, multi-organic failure and death unless there is a rapid identification of the infection and timely administration of treatment. Its mortality rates can reach up to 45.7% for septic shock, its most acute manifestation. In this paper we also present these conditional independence maps in the context of algebraic statistics. The results of this analysis over a small cohort of nine patients at three different times (ICU admission, 48h and ICU discharge) showed that there is a significant interaction between C3- DC / C4-OH (Hydroxybutyrylcarnitine) and C5 (Valerylcarnitin) for the three time snapshots. We also found a significant interaction between C3-DC / C4-OH (Hydroxybutyrylcarnitine) and C5 (Valerylcarnitine) and Isoleucine (Ile) at 48h and ICU discharge.

Acute lung injury (ALI) and Acute Respiratory Distress Syndrome (ARDS) are a clinical manifestation of respiratory failure caused by a response of the lung to local or systemic injury [1]. Damage of alveolar barrier is a critical event in the early stage of ALI/ARDS. Currently there is no effective treatment for this disease. Alveolar type II cells (ATII) are implicated in the alveoli reparation [2] and the transplant of these cells could be a promising ALI treatment.

Study objective To assess the prognostic performance of general severity systems (APACHE II [acute physiology and chronic health evaluation], simplified acute physiology score [SAPS II], and mortality probability models [MPM II]) in coronary patients and to derive new customized indexes for coronary patients using a reduced number of variables. Design Inception cohort. Setting Adult medical and surgical ICUs in 17 hospitals in Catalonia and the Balearic Islands. Patients Four hundred fifty-six patients with acute myocardial infarction. Measurements and results The APACHE II, SAPS II, and MPM II variables and survival status at hospital discharge have been collected. Performance of the severity systems was assessed by evaluating calibration and discrimination. Logistic regression was used to customize the MPM II 24 and SAPS II indexes. Discrimination was high enough for all of the models. However, calibration of the MPM II 24 was not as satisfactory as for the other models. The MPM II 24 and SAPS II were both reduced to five variables (MPM II 24 cor: age, PaO 2 , continuous vasoactive drugs, urinary output, and mechanical ventilation; SAPS II cor : age, PaO 2 /FIo 2 ratio, systolic BP, Glasgow coma score, and urinary output). Both models showed better calibration and discrimination than the original ones. Conclusions Prognostic indexes developed for multidisciplinary patients show good performance when applied to patients with acute myocardial infarction, but customization can reduce the number of variables necessary to compute them without a loss of, and a possible improvement in, prognostic accuracy.

BACKGROUND: Patients with acute respiratory distress syndrome (ARDS) have a deficiency of surfactant. Surfactant replacement improves physiologic function in such patients, and preliminary data suggest that it may improve survival. METHODS: We conducted a prospective, multicenter, double-blind, randomized, placebo-controlled trial involving 725 patients with sepsis-induced ARDS. Patients were stratified according to the risk of death at base line (indicated by their score on the Acute Physiological and Chronic Health Evaluation [APACHE III] index) and randomly assigned to receive either continuously administered synthetic surfactant (13.5 mg of dipalmitoylphosphatidylcholine per milliliter, 364 patients) or placebo (o.45 percent saline; 361 patients) in aerosolized form for up to five days. RESULTS: The demographic and physiologic characteristics of the two treatment groups were similar at base line. The mean (+/- SD) age was 50 +/- 17 years in the surfactant group and 53 +/- 18 years in the placebo group, and the mean APACHE III scores at randomization were 70.4 +/- 25 and 70.5 +/- 25, respectively. Hemodynamic measures, measures of oxygenation, duration of mechanical ventilation, and length of stay in intensive care unit did not differ significantly in the two groups. Survival at 30 days was 60 percent for both groups. Survival was similar in the groups when analyzed according to APACHE III score, cause of death, time of onset and severity of ARDS, presence or absence of documented sepsis, underlying disease, whether or not there was a do-not-resuscitate order, and medical center. Increased secretions were significantly more frequent in the surfactant group; the rates of other complications were similar in the two groups. CONCLUSIONS: The continuous administration of aerosolized synthetic surfactant to patients with sepsis-induced ARDS had no significant effect on 30-day survival, length of stay in the intensive care unit, duration of mechanical ventilation, or physiologic function.

Objective : To compare the performance of three severity of illness scoring systems used commonly for intensive care unit (ICU) patients in a large international data set. The systems analyzed were versions II and III of the Acute Physiology and Chronic Health Evaluation (APACHE) system, versions I and II of the Simplified Acute Physiology Score (SAPS), and versions I and II of the Mortality Probability Model (MPM), computed at admission and after 24 hrs in the ICU. Design : A multicenter, multinational cohort study. Setting : One hundred thirty-seven ICUs in 12 European and North American countries. Patients : During a 3-month period, 14,745 patients were consecutively admitted to 137 ICUs enrolled in the study. Interventions : Collection of information necessary to compute the APACHE II and APACHE III scores, SAPS I and SAPS II, and MPM I and MPM II scores. Patients were followed until hospital discharge. Statistical comparison, including indices of calibration (goodness-of-fit) and discrimination (area under the receiver operating characteristic curve). Measurements and Main Results : Despite having acceptable receiver operating characteristic areas, the older versions of the systems analyzed (APACHE II, SAPS, and MPM I computed at admission-MPM I computed after 24 hrs in the ICU) demonstrated poor calibration for the whole database. The new versions of the systems (SAPS II and MPM II) were superior to their older counterparts. This superiority is reflected by larger receiver operating characteristic areas and better fit. The APACHE III system improved its receiver operating characteristic area compared with the APACHE II system, which showed the best fit of the old systems analyzed. Conclusions : The new versions of the severity systems analyzed (APACHE III, SAPS II, MPM II) perform better than their older counterparts (APACHE II, SAPS I, and MPM I). APACHE II, SAPS II, and MPM II show good discrimination and calibration in this international database. (Crit Care Med 1995 ; 23 :1327-1335)

Sepsis is a major cause of acute lung injury (ALI) and its more severe form, the acute respiratory distress syndrome (ARDS) [1, 2]. In addition, sepsis frequently complicates the clinical course of patients with ALI of other etiologies. The most common cause of ALI/ARDS is pneumonia (bacterial, viral or fungal), followed by severe sepsis from pulmonary or non-pulmonary infections [2, 3]. Sepsis accounts for approximately 25 to 40 % of cases of ALI/ARDS, the risk of ALI being especially high in the presence of intense systemic inflammatory response, shock and multiorgan dysfunction. The association of sepsis with disseminated intravascular coagulation (DIC) also increases the risk of progression to ALI/ARDS [3, 4].

La fibrobroncoscopia (FBC) flexible en el campo de la Medicina Intensiva ha supuesto la introducción de una técnica de gran ayuda para el manejo de pacientes críticamente enfermos. Su seguridad y utilidad, en manos de un profesional adecuadamente entrenado y con las debidas precauciones, ha derivado en un uso cada vez más extendido, incluso en pacientes críticos inestables ventilados mecánicamente y con requerimientos elevados de oxígeno. La Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), mediante el Grupo de Trabajo de Insuficiencia Respiratoria Aguda (GT-IRA) y Enfermedades Infecciosas (GTEI), tiene como objetivo promover el conocimiento y los estándares de calidad de la práctica de la FBC en todos los especialistas de Medicina Intensiva. La SEMICYUC se ha propuesto como objetivo, a través de un comité de expertos, acreditar la formación aportando para ello un currículum, así como las unidades con capacidad para formar en las distintas técnicas y niveles. El proceso de acreditación busca estimular las buenas prácticas de aprendizaje y de calidad en la formación. Tanto el especialista en Medicina Intensiva como otros especialistas médicos y los pacientes se beneficiarán del nivel de compromiso y de control que la acreditación conlleva y del aprendizaje y el entrenamiento que involucra este proceso.

To validate thenar oxygen saturation (StO(2)) measured by near-infrared spectroscopy (NIRS) as a noninvasive estimation of central venous saturation (ScvO(2)) in septic patients.Prospective observational study.A 26-bed medical-surgical intensive care unit at a university-affiliated hospital.Patients consecutively admitted to the ICU in the early phase of severe sepsis and septic shock, after normalization of blood pressure with fluids and/or vasoactive drugs.We recorded demographic data, severity score, hemodynamic data, and blood lactate, as well as ScvO(2), and StO(2) measured simultaneously on inclusion. Patients were divided into two groups according to ScvO(2) values: group A, with ScvO(2)70%, and group B, with ScvO(2)or = 70%.Forty patients were studied. StO(2) was significantly lower in group A than in group B (74.7 +/- 13.0 vs. 83.3 +/- 6.2, P 0.018). No differences in age, severity score, hemodynamics, vasoactive drugs, or lactate were found between groups. Simultaneously measured ScvO(2) and StO(2) showed a significant Pearson correlation (r = 0.39, P 0.017). For a StO(2) value of 75%, sensitivity was 0.44, specificity 0.93, positive predictive value 0.92, and negative predictive value 0.52 for detecting ScvO(2) values lower than 70%.StO(2) correlates with ScvO(2) in normotensive patients with severe sepsis or septic shock. We propose a StO(2) cut-off value of 75% as a specific, rapid, noninvasive first step for detecting patients with low ScvO(2) values. Further studies are necessary to analyze the role of noninvasive StO(2) measurement in future resuscitation algorithms.

Sudden cardiac death is an unresolved problem which causes significant mortality and morbidity in both the community and in-hospital setting. Cardiac arrest is often caused by ventricular tachyarrhythmias which may be mostly interrupted by cardioversion or defibrillation. The single most critical factor for survival is the response time. Over the last 30 years, there have been virtually no procedural changes in the way hospitals address in-hospital resuscitation. A unique device has been developed that eliminates human intervention and assures defibrillation therapy is administered in seconds. This is accomplished with a fully automatic, external bedside monitor defibrillator designed to be prophylactically attached to hospitalized patients at risk of ventricular tachyarrhythmia. The safety and efficacy of the device has been demonstrated in multicenter US and European trials. Thus, this device allows a new scenario which may increase survival and enables meaningful redistribution of health resources.

Edusepsis Study Group., Introduction Although early institution of adequate antimicrobial therapy is lifesaving in sepsis patients, optimal antimicrobial strategy has not been established. Moreover, the benefit of combination therapy over monotherapy remains to be determined. Our aims are to describe patterns of empiric antimicrobial therapy in severe sepsis, assessing the impact of combination therapy, including antimicrobials with different mechanisms of action, on mortality. Methods This is a Spanish national multicenter study, analyzing all patients admitted to ICUs who received antibiotics within the first 6 hours of diagnosis of severe sepsis or septic shock. Antibiotic-prescription patterns in community-acquired infections and nosocomial infections were analyzed separately and compared. We compared the impact on mortality of empiric antibiotic treatment, including antibiotics with different mechanisms of action, termed different-class combination therapy (DCCT), with that of monotherapy and any other combination therapy possibilities (non-DCCT). Results We included 1,372 patients, 1,022 (74.5%) of whom had community-acquired sepsis and 350 (25.5%) of whom had nosocomial sepsis. The most frequently prescribed antibiotic agents were β-lactams (902, 65.7%) and carbapenems (345, 25.1%). DCCT was administered to 388 patients (28.3%), whereas non-DCCT was administered to 984 (71.7%). The mortality rate was significantly lower in patients administered DCCTs than in those who were administered non-DCCTs (34% versus 40%; P = 0.042). The variables independently associated with mortality were age, male sex, APACHE II score, and community origin of the infection. DCCT was a protective factor against in-hospital mortality (odds ratio (OR), 0.699; 95% confidence interval (CI), 0.522 to 0.936; P = 0.016), as was urologic focus of infection (OR, 0.241; 95% CI, 0.102 to 0.569; P = 0.001). Conclusions β-Lactams, including carbapenems, are the most frequently prescribed antibiotics in empiric therapy in patients with severe sepsis and septic shock. Administering a combination of antimicrobials with different mechanisms of action is associated with decreased mortality., We received statistical support from David Suarez, MSc from Unidad de Epidemiologia, Fundación Parc Tauli, Universidad Autónoma de Barcelona. Barcelona, Spain; and data monitoring from Gemma Gomà, research nurse from Centro de Críticos, Hospital de Sabadell. Sabadell, Spain. The Edusepsis Study Group included Ana Navas, Ricard Ferrer, Antonio Artigas et al.

To examine the relationship of expired capnograms and respiratory system resistance (Rrs) in intubated critically ill patients, we consecutively studied 41 mechanically ventilated patients to (1) analyze the association between expired CO2 slope and auto-positive end-expiratory pressure (auto-PEEP), between Rrs and auto-PEEP, between Rrs and expired CO2 slope, and between Rrs and arterial minus end-tidal PCO2 gradient (PaCO2-PETCO2 gradient) and (2) to investigate the capacity of the expired CO2 slope and PaCO2-PETCO2 gradient to predict Rrs during mechanical ventilation. Regression analysis found a close correlation between Rrs and expired CO2 slope (r = 0.86; p0.001), between Rrs and auto-PEEP (r = 0.75; p0.001), and between auto-PEEP and expired CO2 slope (r = 0.74; p0.001). Weak correlation was found between Rrs and PaCO2-PETCO2 gradient (r = 0.48; p0.01). Prediction interval limits at 95 percent confidence level for Rrs are approximately +/- 7.39 cm H2O/L/s from the predicted value obtained by the regression equation, where Rrs = 11.42 + 2.28 expired CO2 slope. These observations suggest that CO2 elimination in critically ill patients is strongly modulated by lung, airway, endotracheal tube, and ventilator equipment resistances. Although continuous capnogram waveform monitoring at the bedside might be useful to assess Rrs, very accurate predictions could be done only in determinate patients.

Pulmonary microvascular cytology consists of analysis of capillary blood sampled while a Swan-Ganz catheter is in the wedge position. This technique has proved to be useful in the diagnosis of lymphangitic spread of carcinoma in the lungs and there are case reports of their use in amniotic fluid embolism. Its usefulness in diagnosing fat embolism syndrome has been shown only rarely. We report a new case in which pulmonary microvascular cytologic study allowed a definite diagnosis of fat embolism syndrome. We suggest obtaining routinely samples of capillary blood when a pulmonary catheter is in place and fat embolism is suspected on a clinical basis.

Correspondencia: Eugenio Berlanga Parc Tauli, s/n 08208 Sabadell (Barcelona) Fax 937162004 e-mail: Eberlanga@cspt.es Introduccion: Exponemos nuestra experiencia en la evaluacion de tutores ligada a una pauta para incentivar la accion tutorial en el programa de formacion de especialistas MIR y FIR. Material y Metodos: Se han disenado dos cuestionarios de evaluacion, uno para el jefe de la unidad docente y otro para la comision de docencia, la suma de los resultados obtenidos en cada uno de ellos sirve para calcular el porcentaje global de objetivos alcanzado. Los cuestionarios se han aplicado a 38 tutores, anualmente, en los anos 2000, 2001 y 2002. Se han utilizado las pruebas de Wilcoxon y de Spearman, aplicando la correccion de Bonferroni, para valorar las diferencias interanuales y la correlacion intraanual de los resultados. Resultados: Los tutores han obtenido un porcentaje medio de objetivos del 92,6% en 2000, del 89,1% en 2001 y del 89,9% en 2002. El cuestionario evaluado por la comision de docencia no muestra diferencias interanuales, mientras que el valorado por los jefes de unidad muestra diferencias entre los anos 2000 y 2002 (P

Objective: To refine the prognosis of critically ill patients using a statistical model that incorporates the daily probabilities of hospital mortality during the first week of stay in the intensive care unit (ICU). Design: Prospective inception cohort. Setting: Fifteen adult medical and surgical ICUs in Spain. Patients: A total of 1,441 patients aged >18 yrs who were consecutively admitted from April 1, 1995, through July 31, 1995. Interventions: Prospective data collection during the stay of the patient in the ICU. Data collected included vital status at hospital discharge as well as all variables necessary for computing the Mortality Probability Models II system at admission and during the first 7 days of stay in the ICU. Measurements and Main Results: Four logistic regression models were obtained. These models contained survival status at hospital discharge as a dependent variable and the following explanatory variables: (model 1) only the probability of dying at admission; (model 2) only the probability of dying during the current day; (model 3) the probability of dying at admission and during the current day; and (model 4) the probabilities of dying at admission and during the previous and current days. Models were evaluated using the Hosmer-Lemeshow statistic and the area under the receiver operating characteristic curve. For survivor and nonsurvivor patients, mortality probabilities obtained using the aforementioned models were compared using linear regression and the paired Student’s t-test. Although severity at admission was a statistically significant variable, models 2 and 3 produced almost the same probabilities of hospital mortality, as shown with the linear regression and paired Student’s t-test results. Conclusions: To have an accurate measurement of the prognosis, it is necessary to update the severity measure. The best estimate of hospital mortality was the probability of death on the current day. Severity at admission and at previous days did not improve the assessment of prognosis. (Crit Care Med 2001; 29:45–50) KEY WORDS: probability models; logistic regression models; hospital mortality; mortality prediction; prognosis; daily assessment; severity of illness index; Mortality Probability Models II system; intensive care; critical illness

Objective To extend the Mortality Probability Models (MPM) II severity system to time periods between 4 and 7 days after admission to the intensive care unit (ICU). Design Prospective inception cohort. Setting Fifteen adult medical and surgical ICUs in Spain. Patients A total of 1,441 patients aged ≥18 yrs consecutively admitted from April 1, 1995 through July 31, 1995. Interventions Prospective data collection during the stay of the patient in the ICU. Data collected included demographic information, length-of-stay and vital status at both ICU and hospital discharge, as well as all variables necessary for computing the MPM II system at admission and during the first 7 days of stay in the ICU Measurements and Main Results Calibration and discrimination of the four existing MPM II models (MPM0, MPM24, MPM48, and MPM72) were assessed in the study database. The MPM II system overestimated the mortality of patients with probabilities of death ≥0.4. The MPM24 model was customized. Models for time periods between 48 hrs and 7 days (MPM48 to MPMd7) were obtained using the same strategy that was used to develop the original MPM48 and the MPM72 models. The variable coefficients of the MPM24 model were kept fixed and the constant terms of the MPM48 to MPMd7 models were estimated by logistic regression. Measurements and Main Results The constant term stabilized after the fourth day of admission and it was similar to the constant term of the MPM72 model. The customized MPM72 performed very well for days 4 to 7 after admission to the ICU. Conclusions If the patient’s condition stays the same day after day, the probability of dying in the hospital increases until 72 hrs, and then stabilizes. A severity measure that performs well at 72 hrs can be a useful tool for measuring severity at later time periods.