Characteristics and survival of patients with acute traumatic spinal cord injury above T6 with prolonged intensive care unit stays

[Abstract] Objective: To characterize patients with acute traumatic spinal cord injury (ATSCI) above T6 who were admitted to the intensive care unit (ICU) for ≥30 days and their 1-year mortality compared with patients admitted for <30 days. Methods: A retrospective observational study was performed on 211 patients with an acute traumatic spinal cord injury above T6 who were admitted to an ICU between 1998 and 2017. Multivariate logistic regression analysis was performed to determine the relationship between an ICU stay ≥30 days and mortality after ICU discharge. Results: Of patients, 29.4% were admitted to the ICU for ≥30 days, accounting for 53.4% of total days of ICU stays generated by all patients. An ICU stay ≥30 days was not identified as an independent risk factor for mortality (1-year survival: 88.5% vs. 88.1%; adjusted hazard ratio [HR] 0.80, P = 0.699). Variables identified as predictors of 1-year post-ICU discharge mortality were severity at admission according to the Acute Physiology and Chronic Health Evaluation II score (HR 1.18) and the American Spinal Injury Association Impairment Scale motor score (HR 0.97). Among patients who required invasive mechanical ventilation, a longer duration of the respiratory support was associated with increased mortality (HR 1.01). Conclusions: Three out of 10 patients with acute traumatic spinal cord injury above T6 require prolonged stays in the ICU. Variables found to be associated with 1-year post-ICU discharge mortality in these patients were American Spinal Injury Association Impairment Scale motor score, severity, and greater duration of invasive mechanical ventilation, but not an ICU stay ≥30 days

Trends in the presentation and management of traumatic spinal cord lesions above T6: 20-Year experience in a tertiary-level hospital in Spain

[Abstract] Objective: To analyze the changes in demographic and lesion characteristics of persons with acute traumatic spinal cord injury (ATSCI) above T6 over a period of 20 years, and to evaluate their impact on ICU resources use, length of stay and mortality.Design: Retrospective observational study.Setting: Intensive Care Unit (ICU) of the University Hospital Complex of A Coruña, Spain.Participants: The study included 241 persons between 1998 and 2017 with an ATSCI above T6. For the purposes of the analysis, the overall study period was divided into three subperiods.Results: Both the mean age of the people with ATSCI (49 vs. 51 vs. 57 years; P = 0.046) and the Charlson Comorbidity Index were higher during the last subperiod (mean: 1.9 ± 2.2; P < 0.01). The most frequent cause of the injury was falls, whose percentage increased over the years. The most common classification in the American Spinal Injury Association Impairment scale was grade A. An increase in the score of the Acute Physiology and Chronic Health Evaluation (APACHE II) score was observed (median: 9 vs. 10 vs. 15; P < 0.01). The length of stay in the ICU has decreased significantly over the years (30 ± 19 vs. 22 ± 14 vs. 19 ± 13 days). No significant differences were found between the rates of ICU or in-hospital mortality recorded over the three subperiods.Conclusions: Despite the progressive increase in the age, comorbidity, and APACHE II, the length of ICU stay decreased significantly, with no associated changes in the mortality rates

Procedural sedation analgesia for enzymatic debridement in patients with burns on face and neck

[Resumen] Introducción y Objetivo. La cantidad de procedimientos mínimamente invasivos realizados fuera del quirófano ha crecido en las últimas décadas. La sedación, la analgesia o ambas, pueden ser nece- sarias para muchos de estos procedimientos de intervención o diagnóstico. Sin embargo, y hasta donde hemos podido conocer, no hay experiencia en el uso de sedoanalgesia para procedimientos (SAP) en pacientes con quemaduras faciales que necesitan desbridamiento enzimático El objetivo de este trabajo es evaluar la eficacia y la seguridad de la SAP para el control del dolor en pacientes con quemaduras faciales sometidos a tratamiento con desbridamiento enzimático. Material y Método. Describimos 16 casos de pacientes adultos con quemaduras en cara y cuello que necesitaron desbridamiento enzimático. Cuatro pacientes sin ventilación mecánica fueron tratados con SAP. Resultados. La SAP generalmente requiere combinación de múltiples agentes para alcanzar los efectos deseados de analgesia más ansiolisis. El procedimiento fue bien tolerado y los pacientes no sufrieron complicaciones. Conclusiones. Presentamos la SAP como opción para el desbridamiento enzimático de quemaduras faciales en pacientes adultos sin ventilación mecánica.[Abstract] Background and Objective. The number of minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades. Sedation, analgesia, or both may be needed for many of these interventional or diagnostic procedures. However, to our knowledge, there is no experience on the use of procedural sedation analgesia (PSA) in patients with facial burns who need enzymatic debridement. The aim of this study is to assess the effectiveness and safety of PSA for pain relief in patients with facial burns undergoing enzymatic debridement. Methods. We describe 16 cases of adult patients with burns on the face and neck who needed enzymatic debridement. Four patients without mechanical ventilation were treated with PSA. The procedure was well tolerated and the patients did not suffer complications Results. PSA usually requires combinations of multiple agents to reach desired effects of analgesia plus anxiolysis. The procedure was well tolerated and the patients did not suffer complications. Conclusions. PSA can be an option for enzymatic debridement of facial burns in adults patients without mechanical ventilation

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

Sedoanalgesia para procedimientos de desbridamiento enzimático en pacientes con quemaduras en cara y cuello

Resumen Introducción y Objetivo La cantidad de procedimientos mínimamente invasivos realizados fuera del quirófano ha crecido en las últimas décadas. La sedación, la analgesia o ambas, pueden ser nece- sarias para muchos de estos procedimientos de intervención o diagnóstico. Sin embargo, y hasta donde hemos podido conocer, no hay experiencia en el uso de sedoanalgesia para procedimientos (SAP) en pacientes con quemaduras faciales que necesitan desbridamiento enzimático El objetivo de este trabajo es evaluar la eficacia y la seguridad de la SAP para el control del dolor en pacientes con quemaduras faciales sometidos a tratamiento con desbridamiento enzimático. Material y Método Describimos 16 casos de pacientes adultos con quemaduras en cara y cuello que necesitaron desbridamiento enzimático. Cuatro pacientes sin ventilación mecánica fueron tratados con SAP. Resultados La SAP generalmente requiere combinación de múltiples agentes para alcanzar los efectos deseados de analgesia más ansiolisis. El procedimiento fue bien tolerado y los pacientes no sufrieron complicaciones. Conclusiones Presentamos la SAP como opción para el desbridamiento enzimático de quemaduras faciales en pacientes adultos sin ventilación mecánica