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To determine the association between armed conflict and very low birth wright (VLBW), which is a multifactorial etiology public health problem that includes aspects of poverty and violence.Case-control population study matched by year of delivery conducted in Cauca, Colombia, between 2010 and 2016. Cases of VLBW, with weights between 500 and 1499 g and controls weighing between 2500 and 3999 g. Cases and controls were identified through the vital statistics registry, and exposure was determined using a multidimensional index designed by the Colombian State. Multiple gestations were excluded. Conditional logistic regression for matched data was used, adjusting for confounding variables.Overall, 7068 matched participants (1767 cases and 5301 controls) were included. Cases and controls had similar baseline characteristics. Participants were predominantly women in the second and third decades of life, 3222 (46%) were exposed to armed conflict, and 1902 (27%) were of African-Colombian or indigenous ethnicity. Maternal exposure to armed conflict significantly increased the odds of VLBW among women with rural birth (adjusted odds ratio [aOR] 3.86, 95% confidence interval [CI] 2.74-5.45) and inadequate prenatal care (aOR 10.38, 95% CI 8.20-13.12).Exposure to armed conflict increases the odds of VLBW neonates. This factor needs to be considered in prenatal care.

Background Patients with obesity have an increased risk for adverse COVID-19 outcomes. Body mass index (BMI) does not acknowledge the health burden associated this disease. The performance of the Edmonton Obesity Staging System (EOSS), a clinical classification tool that assesses obesity-related comorbidity, is compared with BMI, with respect to adverse COVID-19 outcomes. Methods 1071 patients were evaluated in 11 COVID-19 hospitals in Mexico. Patients were classified into EOSS stages. Adjusted risk factors for COVID-19 outcomes were calculated and survival analysis for mechanical ventilation and death was carried out according to EOSS stage and BMI category. Results The risk for intubation was higher in patients with EOSS stages 2 and 4 (HR 1.42, 95% CI 1.02–1.97 and 2.78, 95% CI 1.83–4.24), and in patients with BMI classes II and III (HR 1.71, 95% CI 1.06–2.74, and 2.62, 95% CI 1.65–4.17). Mortality rates were significantly lower in patients with EOSS stages 0 and 1 (HR 0.62, 95% CI 0.42–0.92) and higher in patients with BMI class III (HR 1.58, 95% CI 1.03–2.42). In patients with a BMI ≥ 25 kg/m2, the risk for intubation increased with progressive EOSS stages. Only individuals in BMI class III showed an increased risk for intubation (HR 2.24, 95% CI 1.50–3.34). Mortality risk was increased in EOSS stages 2 and 4 compared to EOSS 0 and 1, and in patients with BMI class II and III, compared to patients with overweight. Conclusions EOSS was associated with adverse COVID-19 outcomes, and it distinguished risks beyond BMI. Patients with overweight and obesity in EOSS stages 0 and 1 had a lower risk than patients with normal weight. BMI does not adequately reflect adipose tissue-associated disease, it is not ideal for guiding chronic-disease management.

RESUMO Considera-se que a transfusão de eritrócitos melhora a respiração celular durante o choque séptico. Contudo, seu impacto agudo no transporte e no metabolismo de oxigênio nessa condição ainda é amplamente debatido. O objetivo deste estudo foi avaliar o impacto da transfusão de eritrócitos na microcirculação e no metabolismo do oxigênio em pacientes com sepse e choque séptico. Conduzimos um levantamento nas bases de dados MEDLINE®, Elsevier e Scopus. Incluímos estudos realizados com seres humanos adultos com sepse e choque séptico. Realizamos uma revisão sistemática e metanálise com utilização do modelo de efeitos aleatórios de DerSimonian e Laird. Consideramos significante valor de p < 0,05. Incluíram-se na análise 19 manuscritos, correspondentes a 428 pacientes. As transfusões de eritrócitos se associaram com aumento de 3,7% na média combinada de saturação venosa mista de oxigênio (p < 0,001), diminuição de razão de extração de oxigênio de -6,98 (p < 0,001) e nenhum efeito significante no índice cardíaco (0,02 L/minuto; p = 0,96). Obtiveram-se resultados similares em estudos que incluíram mensurações simultâneas de saturação venosa mista de oxigênio, razão de extração de oxigênio e índice cardíaco. As transfusões de eritrócitos levaram a aumento significante na proporção de pequenos vasos perfundidos (2,85%; p = 0,553), enquanto os parâmetros de oxigenação tissular revelaram aumento significante no índice de hemoglobina tissular (1,66; p = 0,018). Estudos individuais relataram melhoras significantes na oxigenação tissular e nos parâmetros microcirculatórios sublinguais em pacientes com microcirculação alterada na avaliação inicial. A transfusão de eritrócitos pareceu melhorar o metabolismo sistêmico de oxigênio com aparente independência de variações no débito cardíaco. Observaram-se alguns efeitos benéficos para a oxigenação tissular e parâmetros microcirculatórios, em particular em pacientes com alterações iniciais mais graves. São necessários mais estudos para avaliar seu impacto clínico e individualizar as decisões relativas à transfusão. ABSTRACT Red blood cell transfusion is thought to improve cell respiration during septic shock. Nevertheless, its acute impact on oxygen transport and metabolism in this condition remains highly debatable. The objective of this study was to evaluate the impact of red blood cell transfusion on microcirculation and oxygen metabolism in patients with sepsis and septic shock. We conducted a search in the MEDLINE®, Elsevier and Scopus databases. We included studies conducted in adult humans with sepsis and septic shock. A systematic review and meta-analysis were performed using the DerSimonian and Laird random-effects model. A p value < 0.05 was considered significant. Nineteen manuscripts with 428 patients were included in the analysis. Red blood cell transfusions were associated with an increase in the pooled mean venous oxygen saturation of 3.7% (p < 0.001), a decrease in oxygen extraction ratio of -6.98 (p < 0.001) and had no significant effect on the cardiac index (0.02L/minute; p = 0,96). Similar results were obtained in studies including simultaneous measurements of venous oxygen saturation, oxygen extraction ratio, and cardiac index. Red blood cell transfusions led to a significant increase in the proportion of perfused small vessels (2.85%; p = 0.553), while tissue oxygenation parameters revealed a significant increase in the tissue hemoglobin index (1.66; p = 0.018). Individual studies reported significant improvements in tissue oxygenation and sublingual microcirculatory parameters in patients with deranged microcirculation at baseline. Red blood cell transfusions seemed to improve systemic oxygen metabolism with apparent independence from cardiac index variations. Some beneficial effects have been observed for tissue oxygenation and microcirculation parameters, particularly in patients with more severe alterations at baseline. More studies are necessary to evaluate their clinical impact and to individualize transfusion decisions.

Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous pathophysiologic mechanisms and diverse clinical manifestations. SLE is a frequent cause of intensive care unit (ICU) admissions. Multiple studies with controversial findings on the causes, evolution and outcomes of ICU-admitted patients with SLE have been published. The aim of this paper is to review the literature reporting the clinical characteristics and outcomes, such as mortality and associated factors, in such patients. Among the main causes of ICU admissions are SLE disease activity, respiratory failure, multi-organ failure and infections. The main factors associated with mortality are a high Acute Physiology and Chronic Health Evaluation (APACHE) score, the need for mechanical ventilation, and vasoactive and inotropic agent use. Reported mortality rates are 18.4%–78.5%. Therefore, it is important to evaluate SLE disease severity for optimizing clinical management and patient outcomes.

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Resumen La acidosis lactica es la complicacion mas temida de la intoxicacion por metformina. Presentamos el caso de una mujer de 46 anos que ingresa al servicio de urgencias post paro cardiorrespiratorio, en estado de choque vasoplejico refractario y acidosis lactica tipo B severa tras el consumo de 60 g de metformina. Se inicia la depuracion del toxico con terapia de reemplazo renal (TRR) en el servicio de emergencias. Posteriormente, dada la severidad de la intoxicacion y la consecuente necesidad de TRR prolongada se decide iniciar oxigenacion por membrana extracorporea en su modalidad veno-arterial como estrategia para mantener la perfusion tisular, disminuir la dosis de vasopresores y aumentar la tolerabilidad a la dialisis. La paciente es dada de alta con funcion neurologica preservada y sin necesidad de TRR.

Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

Objective Systemic lupus erythematosus (SLE) is a clinically heterogeneous autoimmune disease, and in some conditions, admission to the intensive care unit (ICUs) is required. This study describes the clinical and prognostic factors in SLE patients admitted to the ICU. Methods We conducted a retrospective study that reviewed all clinical records of patients with SLE admitted to the ICU between 2011 and 2018. Results We evaluated 188 patients, with 279 ICU admissions. Most patients were female ( n = 159; 84.57%) with a median age of 35 years (interquartile range (IQR) = 25–48 years). Infection was the leading cause of admission in 77 (27.60%) cases, followed by lupus flare. The average length of hospitalization was 5 days (IQR 3–11 days), and the SLE Disease Activity Index 2000, Acute Physiology, Age and Chronic Health Evaluation (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores were 9 (IQR 2–17), 14 (IQR 10–17), and 3 (IQR 2–5), respectively. Non-survivors presented with higher APACHE II and SOFA scores. Infection was the leading cause of mortality ( n = 38; 20.21%), and predictors of mortality included invasive mechanical ventilation, vasoactive medication requirement, higher SOFA scores, and antiphospholipid syndrome comorbidity. Conclusions We found that infection was the leading cause of ICU admissions and mortality in patients with SLE. Factors identified here as predictors of mortality should be accurately identified at admission for the prompt treatment of SLE patients.

Report the results obtained following the implementation of an OCC (Obstetric Critical Care) model.This is an observational prospective study in obstetric population with high complexity illness attended in a safety and quality model of attention in a specific unit supporting the concept of obstetric critical care. Records were used as the primary source for collecting information, using the standards of the Center for Clinical Research.In a 5-year period, 10,956 patients were admitted. About 51% had diseases that were not exclusive to pregnancy, 91% were admitted while pregnant and, from all births, 46% were by vaginal delivery. 1685 (19%) patients met the criteria for Near Miss Maternal Mortality (NMMM). Forty-three patients died, which represented a mortality rate of 0.49% of the total of hospitalized patients.The implementation of an OOC model, security models, and an institutional support system improve the quality of care in the obstetric services of reference hospitals in developing countries.

Red blood cell transfusion is thought to improve cell respiration during septic shock. Nevertheless, its acute impact on oxygen transport and metabolism in this condition remains highly debatable. The objective of this study was to evaluate the impact of red blood cell transfusion on microcirculation and oxygen metabolism in patients with sepsis and septic shock. We conducted a search in the MEDLINE®, Elsevier and Scopus databases. We included studies conducted in adult humans with sepsis and septic shock. A systematic review and meta-analysis were performed using the DerSimonian and Laird random-effects model. A p value0.05 was considered significant. Nineteen manuscripts with 428 patients were included in the analysis. Red blood cell transfusions were associated with an increase in the pooled mean venous oxygen saturation of 3.7% (p0.001), a decrease in oxygen extraction ratio of -6.98 (p0.001) and had no significant effect on the cardiac index (0.02L/minute; p = 0,96). Similar results were obtained in studies including simultaneous measurements of venous oxygen saturation, oxygen extraction ratio, and cardiac index. Red blood cell transfusions led to a significant increase in the proportion of perfused small vessels (2.85%; p = 0.553), while tissue oxygenation parameters revealed a significant increase in the tissue hemoglobin index (1.66; p = 0.018). Individual studies reported significant improvements in tissue oxygenation and sublingual microcirculatory parameters in patients with deranged microcirculation at baseline. Red blood cell transfusions seemed to improve systemic oxygen metabolism with apparent independence from cardiac index variations. Some beneficial effects have been observed for tissue oxygenation and microcirculation parameters, particularly in patients with more severe alterations at baseline. More studies are necessary to evaluate their clinical impact and to individualize transfusion decisions.Considera-se que a transfusão de eritrócitos melhora a respiração celular durante o choque séptico. Contudo, seu impacto agudo no transporte e no metabolismo de oxigênio nessa condição ainda é amplamente debatido. O objetivo deste estudo foi avaliar o impacto da transfusão de eritrócitos na microcirculação e no metabolismo do oxigênio em pacientes com sepse e choque séptico. Conduzimos um levantamento nas bases de dados MEDLINE®, Elsevier e Scopus. Incluímos estudos realizados com seres humanos adultos com sepse e choque séptico. Realizamos uma revisão sistemática e metanálise com utilização do modelo de efeitos aleatórios de DerSimonian e Laird. Consideramos significante valor de p0,05. Incluíram-se na análise 19 manuscritos, correspondentes a 428 pacientes. As transfusões de eritrócitos se associaram com aumento de 3,7% na média combinada de saturação venosa mista de oxigênio (p0,001), diminuição de razão de extração de oxigênio de -6,98 (p0,001) e nenhum efeito significante no índice cardíaco (0,02 L/minuto; p = 0,96). Obtiveram-se resultados similares em estudos que incluíram mensurações simultâneas de saturação venosa mista de oxigênio, razão de extração de oxigênio e índice cardíaco. As transfusões de eritrócitos levaram a aumento significante na proporção de pequenos vasos perfundidos (2,85%; p = 0,553), enquanto os parâmetros de oxigenação tissular revelaram aumento significante no índice de hemoglobina tissular (1,66; p = 0,018). Estudos individuais relataram melhoras significantes na oxigenação tissular e nos parâmetros microcirculatórios sublinguais em pacientes com microcirculação alterada na avaliação inicial. A transfusão de eritrócitos pareceu melhorar o metabolismo sistêmico de oxigênio com aparente independência de variações no débito cardíaco. Observaram-se alguns efeitos benéficos para a oxigenação tissular e parâmetros microcirculatórios, em particular em pacientes com alterações iniciais mais graves. São necessários mais estudos para avaliar seu impacto clínico e individualizar as decisões relativas à transfusão.

Mental Health management involve several actors and a high level of services integration. Our objective is to develop a strategy for specifically assessing the quality of Mental Healthcare performance in Catalonia using a methodology developed by AQuAS based on(1): a) to identity the indicators more adequate for the assessment; b) to identify the integrated care programmes for Mental Health (ICP-MH) actives in Catalonia; c) to pilot the implementation of a set of indicators using the Basic Healthcare Areas (BHA) as analysis unit. Methods: Indicators identification: using a structured literature review (Pubmed, grey literature, handmade search). Indicators were classified according the dimensional framework for integrated care assessment developed by AQuAS (2). ICP-MH identification: identified through a documental search (providers’ websites, technical reports, institutional databases such as the Observatori d’Innovacio en Gestio Sanitaria, etc). Main characteristics were collected (pe: presence of a case manager, integral assessment of the patient, individualized plans, etc) in order to determine the degree of integration. BHAs covered by programmes were also identified. Piloting indicators implementation: ratio of observed/expected cases was calculated for each BHA in each indicator for severe mental health disorders (IDC-10 codes). Data belonged to 2015-2016 and were obtained from the Catalan public health system databases (SISCAT). Performance results of BHA with ICP-MH were compared with those without ICP-MH through funnel plots and Poisson regression. Results: Indicators: 343 indicators were identified that mainly belonged to Effectiveness (22,5%) and Accessibility (21,8%) dimensions, followed by Continuity of Care (14,8%) and Efficiency (13,5%). The rest belonged to other dimensions. Programmes: 43 active ICP-MH were identified, mainly in the Health Region of Barcelona (58,1%), then Girona (14,0%), Camp Tarragona (9,3%) and Alt Pirineu & Aran, Lleida and Catalunya Central (2,3% each one). Any programme was found in Terres del Ebre Health Region. Implementation: according to the availability in public health databases were implementes "Readmissions before 30 days", "Urgent admissions", "Average length of stay", and "Length of stay longer than 30 days". Areas with ICP-MH had lower rates of readmissions, urgent admissions, and lengths of stay longer than 30 days. Discussions: Both the heterogeneity of the ICP-MH and the lack of indicators available fully addressed to integrated care complicate the assessment. Conclusions: BHA with ICP-MH had a better performance on hospital indicators when compared with areas without ICP-MH regarding severe mental disorders. Lessons learned: - indicators identified focused on Efectiveness rather than in Continuity or Integrated Care - there are several differences in the concept of "integrated care" - public Catalan databases are not ready for assessing ICP-MH Limitations: - lack of structured information about ICP-MH - the number of available indicators in mental health public databases is small and sometimes of low quality - available indicators in public databases don’t capture integrated care attention Suggestions for future research: The list of identified indicators will be validated with professionals, careers and patients for choosing those that better captures the quality of care. References: 1- Robles N, et al. Int J Integr Care. 2017;17(5):A389. 2- Espallargues M, et al. Rev Esp Salud Publica. 2016;90:1–16

Introduction Present a review of the case, management, and progress of an obstetric patient who suffered a car accident with subsequent severe blunt thoracic trauma (BTT) resulting in flail chest (FC). Case report This is a case of Hispanic female of 44 years involved in a car accident at 14 weeks of gestation, who presented with FC, sternal fracture, and severe respiratory compromise. This woman received surgical management and care in an intensive obstetric care unit management, presenting osteomyelitis as a complication, along with physical deconditioning and prolonged hospital stay, finally with an obstetric and functional favorable outcome. Conclusion Although severe BTT in pregnant patients is uncommon, it is important to highlight the appropriate medical management required for these patients in order to achieve a successful outcome, as was in this case. This is the only case report of FC surgical management in pregnancy that we have in our institution so far. How to cite this article Nieto AJ, Velásquez M, Escobar MF, Carvajal JA, Granados M. Unstable Chest Surgical Management in Pregnancy: Case Report and Literature Review. Panam J Trauma Crit Care Emerg Surg 2016;5(3):155-160.

Resumen Introducción: El oxígeno (O2) es un medicamento que puede generar efectos adversos. Discrepancias en la lectura del flujómetro y metas de saturación de oxígeno (SpO2) pueden repercutir en la toma de decisiones clínicas, paraclínicas y estancia hospitalaria de pacientes pediátricos. Objetivo: Evaluar conocimientos sobre SpO2, efectos adversos del O2 y lectura del flujómetro en el personal de salud del Departamento de Pediatría del Hospital Universitario San Ignacio, Bogotá, Colombia. Métodos: Estudio transversal, mediante encuesta autodiligenciada en una muestra por conveniencia durante diciembre de 2016 y enero de 2017. Evaluación de conocimientos sobre oxigenoterapia, SpO2, efectos adversos y lectura del flujómetro mediante fotografías de flujómetros del hospital con diferente fracción inspirada de oxígeno (FiO2). Resultados: De 259 personas, el 77 % respondió la encuesta. El 22 % de los participantes respondió que la SpO2 aumenta o se mantiene igual cuando el niño duerme; el 78 % sabía de complicaciones del uso prolongado de O2, y el 67 %, las relacionadas con la administración de una FiO2 mayor a la necesaria. Con relación a la población neonatal, el 10 % consideró que se deben buscar metas de SpO2 iguales o superiores al 96 %; entre el 9 % y el 19 % de las lecturas en las diferentes fotografías de flujómetros fueron respuestas incorrectas. Discusión: Es necesario reforzar conceptos actualizados sobre oxigenoterapia, con énfasis en metas de saturación, efectos adversos y lectura de flujómetro mediante campañas educativas periódicas. Abstract Introduction: Supplemental oxygen is considered a pharmaceutical drug; therefore, it can produce adverse effects. Lack of consensus regarding the reading of oxygen flowmeters and the peripheral oxygen saturation (SpO2) goals can influence clinical and paraclinical decisions and hospital stay length. Objective: To assess knowledge on oxygen therapy, adverse effects, SpO2 goals and reading of oxygen flowmeters among personnel in the Pediatric Unit at Hospital Universitario San Ignacio, Bogotá, Colombia. Methodology: Cross-sectional study derived from convenience sampling through a self-applied survey between December 2016 and January 2017. The poll evaluated topics on supplemental oxygen therapy fundamentals and adverse effects, SpO2 goals and flowmeter readings through flowmeters photographs indicating a specific fraction of inspired oxygen (FiO2). Results: The response rate was 77% from 259 subjects. 22% considered that the oxygen saturation either increases or remains the same during sleep periods in children. 78% of participants knew at least one complication associated to prolonged oxygen therapy and 67% due to supplemental oxygen concentration greater than required. In neonatal population, 10 % considered oxygen saturation goals equal to or greater than 96%. In the flowmeter’s reading evaluation, incorrect answers ranged from 9 to 19%. Conclusion: It is imperative to reinforce updated concepts on oxygen therapy, with emphasis in SpO2 goals, adverse effects and appropriate flowmeter’s readings through periodic educational campaigns.

Background The life expectancy of HIV patients has increased with antiretroviral therapy which has reduced the incidence of AIDS-associated illnesses. Longer life expectancy increases noncommunicable diseases cases and the demand for intensive care unit (ICU) care. ICU mortality is higher among HIV patients. Information about mortality and other relevant outcomes among HIV patients from developing countries is paramount for benchmarking purposes. This study aimed to evaluate the mortality of patients with HIV/AIDS admitted to the ICU during the years 1999 to 2015. Methods An observational retrospective study was conducted based on episodes of patients admitted to the ICU of the Fundación Valle del Lili from December 1998 to October 2015. The Cochran-Armitage test was used to evaluate the trend of HIV mortality by 4-year periods, considering sex and age groups ( 50 years). The Z test compared the mortality between HIV patients with non-HIV patients in the ICU; also it compared the mortality in HIV patients by sex and age group. Results A total of 53,798 episodes of ICU admissions were analyzed, 0.76% (414) were HIV patients, and of this 78.5% were men. Twenty-three percent were over 50 years old. Overall mortality in the ICU was 9.13%, and the mortality in HIV patients was 22.03%, which was higher when compared with a non-HIV group (9%, P < 0.001). Mortality due to HIV had a statistically significant decreasing trend (P < 0.001), going from 40% between 1999 and 2003 to 18.04% between 2012–2015, this trend was observed among men with HIV (P < 0.001) starting with 43. 5% and ending at 20%, but among women the decreasing trend was not statistically significant (P = 0.62). Mortality for HIV decreased, in the Conclusion This study found a statistically significant trend for mortality decrease over a 16-year period among HIV patients admitted to an ICU from a developing country. Disclosures All authors: No reported disclosures.

Background Dengue mortality can be preventable in endemic regions. However, access to intensive care units (ICU) and continuous monitoring strategies are limited in developing countries. In 2010, WHO dengue clinical practice guidelines (CPG) were implemented in the Americas region which strengthened hospital healthcare management and prioritized early ICU admission in severe dengue cases. We hypothesized that early access to the ICU might decrease the mortality of patients with dengue. This study aimed to describe trends in dengue cases and mortality in the ICU for 15 years in Cali, Colombia. Methods An observational retrospective study about dengue cases treated in adult ICU was conducted, in the Fundación Valle del Lili. We included cases between 2001 to 2015 years. Clinical data were collected from the ICU database and medical charts. A Cochran-Armitage test for trend was used to assess the presence of an association between fatal cases and total cases in dengue patients at ICU during the study period, and to evaluate differences in the mortality cases before and after the implementation of the dengue CPG. Results A total of 49,962 episodes of attention in ICU were analyzed, and 70 cases with severe dengue and dengue shock attended in ICU were included. The median age was 42 years (IQR = 24–60), eight cases were older than 65 years, and 54% were male. Five fatal cases were reported during this period. The fatal cases had a length of stay in ICU of 2 days (IQR = 1–4) vs. 2 days (IQR = 1–3) for nonfatal cases. Overall mortality for dengue cases in the ICU was 7.14%. The highest mortality was presented in 2007 with 33.33% (1/3), and after 2010 there were no fatal cases. Dengue mortality showed a decreasing linear variation over time in the ICU (p = 0.047); also there was a statistically significant difference over time in adults mortality before and after of implementation of dengue CPG (P = 0.029). Conclusion Dengue mortality cases in the ICU have decreased in the last 15 years, which is related to early admission to the ICU and continuous clinical monitoring. Disclosures All authors: No reported disclosures.

Resumen Fundamento y objetivo La relacion del lactato y la mortalidad en sepsis no ha sido explorada adecuadamente en el paciente normotenso. Nuestro objetivo fue determinar la utilidad del lactato como factor pronostico de mortalidad a los 28 dias en pacientes admitidos en el Servicio de Urgencias con diagnostico clinico de sepsis y sin shock septico. Pacientes y metodo Analisis secundario del estudio La epidemiologia de la sepsis en Colombia , una cohorte prospectiva de pacientes en 10 hospitales generales de 4 ciudades de Colombia. Se incluyeron en este analisis los pacientes sin hipotension, con disponibilidad de lactato y admitidos con infecciones adquiridas en la comunidad confirmadas con los criterios de los Centers for Disease Control and Prevention . Se realizo una regresion logistica controlando para la edad, el sexo, las comorbilidades y la puntuacion de gravedad. Resultados Se incluyeron 961 pacientes, con edad media (DE) de 57,2 (21,0) anos, el 54,2% eran mujeres, la puntuacion SOFA (Sequential Organ Failure Assessment) promedio fue de 3,0 (2,3) y el APACHE (Acute Physiologic and Chronic Health Evaluation) de 11,1 (6,4). Se observo un buen ajuste al modelo lineal entre el lactato y el riesgo de muerte, y al ajustar por los factores de confusion el lactato se asocio de manera significativa con la mortalidad ( odds ratio 1,16, intervalo de confianza del 95% 1,02-1,33). Conclusion El valor de lactato se asocia de forma independiente y significativa con la mortalidad a los 28 dias entre los pacientes con infeccion que se presentan en el Departamento de Urgencias sin hipotension. Ademas, la mortalidad se incrementa de manera lineal con los valores de lactato serico a partir de cualquier valor detectable.

Objetivo: describir las características sociodemográficas y clínicas, así como las complicaciones de los pacientes que ingresaron a la unidad de cuidado intensivo por crisis asmática severa. Metodología: estudio descriptivo de pacientes admitidos en la unidad de cuidado intensivo por crisis asmática severa. La información de características demográficas, manejo farmacológico previo a la hospitalización, necesidad de soporte ventilatorio invasivo (VMI), manejo farmacológico para controlar la crisis y complicaciones hospitalarias incluyendo la muerte fueron recolectadas en el período entre enero 2011 a diciembre de 2014. Resultados: hubo 72 episodios de crisis asmática severa con ingreso a la unidad de cuidado intensivo. La mediana de edad fue 42 años (rango intercuartil 29-59); 81% fueron mujeres y 23 pacientes (31,94%) fueron manejados con VMI. El grupo de pacientes en VMI tuvo menor tiempo de duración de síntomas previo al evento, el pH más bajo al ingreso y durante la hospitalización, y estancias hospitalarias más prolongadas. La mediana de días ventilación mecánica fue 2. Hubo dos muertes por asma (2,78%), 3 presentaron encefalopatía hipóxica isquémica (4,17%) y la complicación más frecuente fue hipokalemia, en 39% de los casos con VMI. La neumonía asociada al cuidado de salud fue más frecuente en el grupo que requirió ventilación mecánica no invasiva (24,24%) y 2 de 23 pacientes en VMI (8,7%) requirieron traqueostomía. Conclusiones: las crisis asmáticas severas son una causa importante de admisión a cuidado intensivo en Colombia y Latinoamérica; causan alta morbilidad, sin embargo su mortalidad es baja (2,78%). Se requieren estrategias definidas para prevenir estos episodios y asegurar el seguimiento oportuno de los pacientes ambulatorios después del evento.

Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital-based population in Colombia.Prospective cohort.Ten general hospitals in the four main cities of Colombia.Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions.None.The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (SD = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5-19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (SD = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (SD = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%.In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score.

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A “clinical” model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score ( P value = 0.049), abdominal trauma index ( P value = 0.049), and acute physiology and chronic health evaluations II ( P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the “clinical” model and revised trauma score ( P value = 0.4) and trauma score-injury severity score ( P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.

Introducción y objetivo: En Colombia faltan datos fiables sobre el comportamiento de la sepsis. Se pretende determinar la prevalencia de los microorganismos en las principales infecciones tratadas en las unidades de cuidados intensivos (UCI) de nuestro país. Métodos: Este es un subestudio de una cohorte prospectiva recolectada en 10 hospitales durante 6 meses. Los criterios de inclusión eran hospitalización en UCI y confirmación de una infección según las definiciones del CDC, considerando tres grupos (comunidad, hospital, UCI) según el sitio de adquisición de la infección. Resultados: Se incluyó en el análisis a 826 pacientes; el 51% contrajeron procesos infecciosos extrahospitalarios; el 5,33%, en el hospital y el 43,7%, en UCI. Los diagnósticos más frecuentes fueron neumonía (29,54%), infección intraabdominal (18,16%) e infección del tracto urinario (11,62%). El microorganismo más frecuente en las infecciones extrahospitalarias fue Escherichia coli -pulmón (16,4%), peritoneo (57,7%), orina (55,5%) y sangre (22,4%)-. En las adquiridas en UCI predomina también E. coli -peritoneo (29,3%) y orina (52,9%)-, excepto en pulmón y sangre, en los que fueron Staphylococcus aureus (32,4%) y Klebsiella pneumoniae (15,7%) los más prevalentes. Se tomaron cultivos a 655 pacientes, de los que el 40% recibió antibióticos antes de la toma, sin que esto afectara al porcentaje de positividad (p=0,583). Conclusiones: La neumonía fue la infección más frecuente independientemente del sitio de adquisición. E. coli fue el patógeno más prevalente, excepto en las infecciones pulmonares adquiridas en UCI, donde lo fue S. aureus. Background and objective: Valid and reliable data regarding sepsis is lacking in Colombia. Our aim was to determine the prevalence of the microorganisms in the main infections treated in Intensive Care Units (ICUs) in our country. Methods: This is a sub-study of a prospective cohort with 10 general hospitals in Colombia during a 6-month period. The inclusion criteria were hospitalization in ICU and confirmation of infection according to the CDC definitions. Patients were classified into three groups, that is, community, hospital and intensive care, according to the site where the infection was acquired. Results: A total of 826 patients were included in this analysis. Of these, 51% developed infections in the community, 5.33% in the hospital and 43.7% in intensive care unit. Overall, the most common diagnoses were pneumonia (29.54%), intra-abdominal infection (18.16%) and urinary tract infection (11.62%). The most frequent germ in community-acquired infections was E. coli -lung (16. 4%), peritoneum (57.7%), urine (55.5%), blood (22.4%)-. E. coli -peritoneum (29.3%), urine (52.9%)- also predominated in the ICU-acquired infections, except for lung and blood in which Staphylococcus aureus (32.4%) and Klebsiella pneumoniae (15.7%) were the most prevalent. Cultures were requested from 655 patients, 40% of them having received antibiotics before cultures were taken, although this did not affected the percentages of positive cultures (P=0.583). Conclusions: Pneumonia was the main cause of infection regardless of the site of acquisition. E. coli was the most prevalent germ, except in the pulmonary infections acquired in UCI in which S. aureus was the most prevalent.

Purpose: To evaluate the prognostic value of the Cv-aCO2/Da-vO2 ratio combined with lactate levels during the early phases of resuscitation in septic shock. Methods: Prospective observational study in a 60-bed mixed ICU. One hundred and thirty-five patients with septic shock were included. The resuscitation protocol targeted mean arterial pressure, pulse pressure variations or central venous pressure, mixed venous oxygen saturation, and lactate levels. Patients were classified into four groups according to lactate levels and Cv-aCO2/Da-vO2 ratio at 6 h of resuscitation (T6): group 1, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 >1.0; group 2, lactate ≥2.0 mmol/L and Cv-aCO2/Da-vO2 ≤1.0; group 3, lactate 2/Da-vO2 >1.0; and group 4, lactate 2/Da-vO2 ≤1.0. Results: Combination of hyperlactatemia and high Cv-aCO2/Da-vO2 ratio was associated with the worst SOFA scores and lower survival rates at day 28 [log rank (Mantel–Cox) = 31.39, p 2/Da-vO2 ratio and lactate 2/Da-vO2 ratio. The multivariate analysis revealed that Cv-aCO2/Da-vO2 ratio at both T0 (RR 3.85; 95 % CI 1.60–9.27) and T6 (RR 3.97; 95 % CI 1.54–10.24) was an independent predictor for mortality at day 28, as well as lactate levels at T6 (RR 1.58; 95 % CI 1.13–2.22). Conclusion: Complementing lactate assessment with Cv-aCO2/Da-vO2 ratio during early stages of resuscitation of septic shock can better identify patients at high risk of adverse outcomes. The Cv-aCO2/Da-vO2 ratio may become a potential resuscitation goal in patients with septic shock., SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction Venous-to-arterial carbon dioxide difference (Pv-aCO2) may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic shock patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters. Methods We conducted a prospective observational study in a 60-bed mixed ICU in a University affiliated Hospital. 85 patients with a new septic shock episode were included. A Pv-aCO2 value ≥ 6 mmHg was considered to be high. Patients were classified in four predefined groups according to the Pv-aCO2 evolution during the first 6 hours of resuscitation: (1) persistently high Pv-aCO2 (high at T0 and T6); (2) increasing Pv-aCO2 (normal at T0, high at T6); (3) decreasing Pv-aCO2 (high at T0, normal at T6); and (4) persistently normal Pv-aCO2 (normal at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and Pv-aCO2. Finally, we calculated the mortality risk ratios at day-28 among patients attaining normal oxygen parameters but with a concomitantly increased Pv-aCO2. Results Patients with persistently high and increasing Pv-aCO2 at T6 had significant higher SOFA scores at day-3 (p < 0.001) and higher mortality rates at day-28 (log rank test: 19.21, p < 0.001) compared with patients who evolved with normal Pv-aCO2 at T6. Interestingly, a poor agreement between cardiac output and Pv-aCO2 was observed (r2 = 0.025, p < 0.01) at different points of resuscitation. Patients who reached a central venous saturation (ScvO)2 ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65% but with concomitantly high Pv-aCO2 at different developmental points (i.e., T0, T6 and T12) had a significant mortality risk ratio at day-28. Conclusion The persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28. Although mechanisms conducting to increase Pv-aCO2 during septic shock are insufficiently understood, Pv-aCO2 could identify a high risk of death in apparently resuscitated patients.

Background Sepsis has several clinical stages, and mortality rates are different for each stage. Our goal was to establish the evolution and the determinants of the progression of clinical stages, from infection to septic shock, over the first week, as well as their relationship to 7-day and 28-day mortality. Methods This is a secondary analysis of a multicenter cohort of inpatients hospitalized in general wards or intensive care units (ICUs). The general estimating equations (GEE) model was used to estimate the risk of progression and the determinants of stages of infection over the first week. Cox regression with time-dependent covariates and fixed covariates was used to determine the factors related with 7-day and 28-day mortality, respectively. Results In 2681 patients we show that progression to severe sepsis and septic shock increases with intraabdominal and respiratory sources of infection [OR = 1,32; 95%IC = 1,20-1,46 and OR = 1.21, 95%CI = 1,11-1,33 respectively], as well as according to Acute Physiology and Chronic Health Evaluation II (APACHE II) [OR = 1,03; 95%CI = 1,02-1,03] and Sequential Organ Failure Assessment (SOFA) [OR = 1,16; 95%CI = 1,14-1,17] scores. The variables related with first-week mortality were progression to severe sepsis [HR = 2,13; 95%CI = 1,13-4,03] and septic shock [HR = 3,00; 95%CI = 1,50-5.98], respiratory source of infection [HR = 1,76; 95%IC = 1,12-2,77], APACHE II [HR = 1,07; 95% CI = 1,04-1,10] and SOFA [HR = 1,09; 95%IC = 1,04-1,15] scores. Conclusions Intraabdominal and respiratory sources of infection, independently of SOFA and APACHE II scores, increase the risk of clinical progression to more severe stages of sepsis; and these factors, together with progression of the infection itself, are the main determinants of 7-day and 28-day mortality.

Currently, there is not enough data available concerning sepsis in developing countries, especially in Latin America.We developed a study aimed at determining the frequency, clinical and epidemiological characteristics, and the consequences of sepsis in patients requiring admission to intensive care units in Colombia.This was a secondary analysis of a prospective cohort study carried out over a six-month period, from September 1, 2007, to February 28, 2008, in ten medical/surgical intensive care units in four Colombian cities. Patients were considered eligible if they had a probable or confirmed diagnosis of infection according to medical records. We recorded demographic characteristics, first admission diagnosis and co-morbidities, clinical status, and sepsis, severe sepsis or septic shock.During the study period, 826 patients were admitted to the intensive care units. From these patients, 421 (51%) developed sepsis in the community, 361 (44%) in the ICU, and 44 (5%) during hospitalization in the general ward. Two hundred and fifty three patients (30.6%) had involvement of one organ system: 20% had respiratory involvement, followed by kidney and central nervous system involvement with 3.4% and 2.7%, respectively.In our cohort of septic patients, the prevalence of sepsis treated in ICU is similar to that reported in other studies, as well as the overall mortality.

Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal.Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18 years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient's abdomen. Patients were grouped according to the duration in days of their AP in1, 1-2, 2-3, and3 days.Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1± 11.5 years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6±7.2. The mean Injury Severity Score (ISS) score was 24.9±9.1. The right upper quadrant was packed in 39 (32.2%) patients, retroperitoneum in 70 (57.8%), pelvis in 13 (10.7%), and left upper quadrant in 9 (7.4%). Fifty-one patients (42.1%) had associated colon injuries and 58 (47.9%) had small bowel injuries. Twenty-six patients (21.5%) had AP1 day, 42 patients (34.7%) had AP between 1 and 2 days, 35 patients (28.9%) had AP between 2 and 3 days, and 18 patients (14.8%) had AP3 days. The re-bleeding rate in patients packed for 1-2 days compared to those packed for1 day was a third lower, 14.3%, (95% confidence interval [95% CI]: 8.06, 20.5) versus 38.5% (95% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7% (95% CI: 6.6, 26.7) to 44.4% (95% CI: 31.03, 57.7) when comparing 1-2 days versus3 days. Overall mortality was 16.5%. Of these deaths, 8.26% were attributable to re-bleeding, and 13.2% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value=0.04).The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2-3 days, and AP left in longer than 3 days is associated with a significantly increased risk of infectious complications.

The relationship between lactate and mortality in patients without hypotension has not been appropriately explored. Our aim was to determine the usefulness of serum lactate as a prognostic factor of 28-day mortality in patients admitted to the Emergency Department with clinical diagnosis of sepsis without septic shock.We performed a secondary analysis of the study The epidemiology of sepsis in Colombia, a prospective cohort of patients from 10 general hospitals in 4 Colombian cities. We analyzed patients without hypotension with serum lactate available and admitted with community-acquired infections, which were confirmed according to the Centers for Disease Control and Prevention CDC criteria. A logistical regression was performed adjusting for age, sex, comorbidities and severity scores.We included 961 patients aged 57.2 ± 21.0 years, 54.2% were females, mean SOFA score was 3.0 ± 2.3 and APACHE score was 11.1±6.4. We observed a linear relationship between serum lactate and the odds of death, and after adjustment there was a significant and independent association between lactate and mortality (odds ratio 1,16, 95% confidence interval 1.02-1.33).Serum lactate is independently and significantly associated with 28-day mortality among patients with infection who present to the Emergency Department without hypotension. Besides, mortality increases in a linear way with serum lactate from any detectable value.

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A "clinical" model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score (P value = 0.049), abdominal trauma index (P value = 0.049), and acute physiology and chronic health evaluations II (P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the "clinical" model and revised trauma score (P value = 0.4) and trauma score-injury severity score (P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.

Resumen Introduccion y objetivo En Colombia faltan datos fiables sobre el comportamiento de la sepsis. Se pretende determinar la prevalencia de los microorganismos en las principales infecciones tratadas en las unidades de cuidados intensivos (UCI) de nuestro pais. Metodos Este es un subestudio de una cohorte prospectiva recolectada en 10 hospitales durante 6 meses. Los criterios de inclusion eran hospitalizacion en UCI y confirmacion de una infeccion segun las definiciones del CDC, considerando tres grupos (comunidad, hospital, UCI) segun el sitio de adquisicion de la infeccion. Resultados Se incluyo en el analisis a 826 pacientes; el 51% contrajeron procesos infecciosos extrahospitalarios; el 5,33%, en el hospital y el 43,7%, en UCI. Los diagnosticos mas frecuentes fueron neumonia (29,54%), infeccion intraabdominal (18,16%) e infeccion del tracto urinario (11,62%). El microorganismo mas frecuente en las infecciones extrahospitalarias fue Escherichia coli —pulmon (16,4%), peritoneo (57,7%), orina (55,5%) y sangre (22,4%)—. En las adquiridas en UCI predomina tambien E. coli —peritoneo (29,3%) y orina (52,9%)—, excepto en pulmon y sangre, en los que fueron Staphylococcus aureus (32,4%) y Klebsiella pneumoniae (15,7%) los mas prevalentes. Se tomaron cultivos a 655 pacientes, de los que el 40% recibio antibioticos antes de la toma, sin que esto afectara al porcentaje de positividad (p = 0,583). Conclusiones La neumonia fue la infeccion mas frecuente independientemente del sitio de adquisicion. E. coli fue el patogeno mas prevalente, excepto en las infecciones pulmonares adquiridas en UCI, donde lo fue S. aureus .

There is inconclusive data on whether critically ill individuals with severe secondary peritonitis requiring multiple staged laparotomies may became eligible candidates for deferred primary anastomoses (DPA). We sought to compare a protocol for DPA against a protocol for diversion in severely ill critical patients with intra-abdominal sepsis. A retrospective cohort study was performed examining 112 patients admitted through an ICU between 2002 and 2006, with diagnosis of secondary peritonitis and managed with staged laparotomies whom required small- or large-bowel segment resections. Patients were categorized and compared according to the surgical treatment necessitated to resolve the secondary peritonitis (DPA versus diversion). Outcome measures were days on mechanical ventilation, days required in ICU, days required in hospital, incidence of fistulas/leakages, acute respiratory distress syndrome (ARDS), and mortality. There were 34 patients subjected to DPA and 78 to diversion. Fistulas/leakages developed in three patients (8.8%) with DPA and four patients (5.1%) with diversion (p = 0.359). ARDS was present in 6 patients (17.6%) with DPA and 24 patients (30.8%) with diversion (p = 0.149). There were 30 patients (88.2%) with DPA and 65 patients (83.3%) with diversion discharged alive (p = 0.51). There were not statistical significant differences between groups among survivors regarding hospital length of stay, ICU length of stay, and days on mechanical ventilation. We did not find significant differences in morbidity or mortality when we compared DPA versus diversion surgical treatment. It is feasible to perform a primary anastomosis in critically ill patients with severe secondary peritonitis managed with staged laparotomies.

Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication seen in patients with systemic lupus erythematosus (SLE). This paper describes the clinical features and outcome of seven SLE patients with DAH admitted to a medical intensive care unit (ICU) in a referral center. Of a total of 122 SLE patients, seven patients presented this complication (5.7%). Five patients were women (71.4%). Mean age was 24.3 (range 4-51 years). Mean duration of SLE before clinical DAH was 15.7 months (range 0-48 months). DAH was the initial manifestation of SLE in two patients (29%). DAH recurrence was seen in two patients (29%). Active lupus was present in all seven patients. Fever, glomerulonephritis, arthritis, myositis, and peripheral neuropathy were observed in six, four, four, three, and two patients, respectively. Five patients who underwent to bronchoscopy had positive findings of DAH (71.4%; i.e., bloody return on bronchoalveolar lavage--with hemosiderin-laden macrophages). Treatment options included intravenous methylprednisolone (10 mg kg(-1) day(-1)--3 days) following by prednisolone 1 mg kg(-1) day(-1) and pulse cyclophosphamide (750 mg/m(2)). Plasmapheresis was added in four patients (57.1%) because of the persistence of DAH. All patients were treated in an ICU, six of them requiring mechanical respiratory support (85.1%). Mortality rate during ICU stay was 12% (one patient). Our results show that DAH is an uncommon complication in SLE patients, requiring a prompt and aggressive recognition and treatment with high-dose steroid, intravenous cyclophosphamide, and plasmapheresis. With all of these treatments, there is a trend to a low mortality rate in patients with SLE presenting DAH.