Extracorporeal membrane oxygenation (ECMO): Initial experience at our hospital for acute severe respiratory failure in adults

La oxigenación por membrana extracorpórea (ECMO) es una forma de soporte vital extracorpóreo. Un circuito o sistema de circulación artificial externo conduce sangre venosa desde el paciente a un oxigenador, donde se añade oxígeno y se desprende dióxido de carbono, y a continuación, la sangre se devuelve a la circulación del paciente. Dependiendo de si su configuración es venovenosa (VV) o venoarterial, la ECMO se utiliza como apoyo temporal de la función respiratoria, de la función circulatoria o de ambas. El objetivo de este artículo es presentar la experiencia inicial del hospital universitario Son Espases (Palma) con el sistema ECMO VV al tratarse del único centro en las Islas Baleares capaz de ofrecer dicho tratamiento.Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support. An external artificial circulation or circuit carries venous blood from the patient to an oxygenator, where oxygen is added and carbon dioxide removed, then the blood is returned to the patient circulation. Depending on its configuration –venovenous (VV) or venoarterial–, ECMO is temporarily used to support respiratory function, circulation, or both. The objective of this publication is to review the initial experience at Son Espases University Hospital (Palma) using VV ECMO, unique centre in the Balearic Island with the capability of providing this therapy

Instal·lacions de baix risc de proliferació i dispersió de legionel·la: anàlisi de circuits i eines de control

Legionel·la; Control oficial; Seguretat ambientalLegionela; Control oficial; Seguridad ambientalLegionella; Official control; Environmental securityAquesta Comunitat de Pràctica (CoP) es va crear amb l’objectiu de disposar d’uns documents, consensuats per tècnics de les diferents administracions implicades en el control i la prevenció de la legionel·losi (ASPCAT, DIBA, municipis, i, fins i tot, el Govern andorrà), perquè siguin una eina pràctica de treball. En un mateix model s’inclou la normativa, la informació ja disponible i les recomanacions tècniques per a aquells paràmetres que no conté ni la normativa ni la informació complementària ja disponible. D’una banda, aquests documents han de permetre la inspecció, tant als tècnics de l’ASPCAT com als tècnics municipals i/o a altres institucions encarregades de fer aquestes tasques. D’una altra banda, han de servir per donar suport a tots els agents implicats en la gestió i el control d’aquestes instal·lacions de baix risc. Presentem la documentació generada fins ara. Som conscients que no està del tot acabada i esperem que aquesta CoP tingui la continuïtat necessària per tal de concloure aquests documents i, si és possible, d’ampliar-los a altres instal·lacions de baix risc. Esperem que això ajudi a millorar l’estat higienicosanitari de les instal·lacions considerades de baix risc i a disminuir els brots i els casos de legionel·losi que, en els darrers anys, s’ha detectat que podrien ser les principals causants d’aquesta malaltia al nostre territori.Esta Comunidad de Práctica (CoP) se creó con el objetivo de disponer de unos documentos, consensuados por técnicos de las diferentes administraciones implicadas en el control y la prevención de la legionelosis (ASPCAT, DIBA, municipios, y, hasta y todo, el Gobierno andorrano), para que sean una herramienta práctica de trabajo. En un mismo modelo se incluye la normativa, información ya disponible y recomendaciones técnicas para aquellos parámetros que no contiene ni la normativa ni la información complementaria ya disponible. Por un lado, estos documentos deben permitir la inspección, tanto a los técnicos de la ASPCAT como a los técnicos municipales y/oa otras instituciones encargadas de realizar estas tareas. Por otro lado, deben servir para apoyar a todos los agentes implicados en la gestión y control de estas instalaciones de bajo riesgo. Presentamos la documentación generada hasta ahora. Somos conscientes de que no está del todo terminada y esperamos que esta CoP tenga la continuidad necesaria para concluir estos documentos y, si es posible, ampliarlos a otras instalaciones de bajo riesgo. Esperamos que esto ayude a mejorar el estado higiénico-sanitario de las instalaciones consideradas de bajo riesgo ya disminuir los brotes y los casos de legionelosis que, en los últimos años, se ha detectado que podrían ser las principales causantes de ésta enfermedad en nuestro territorio.This Community of Practice (CoP) was created with the aim of having some documents agreed upon by technicians from the different administrations involved in the control and prevention of legionellosis (ASPCAT, DIBA, municipalities, and, even and all, the Government Andorran), so that they are a practical work tool. The same model includes the regulations, information already available and technical recommendations for those parameters that neither the regulations nor the complementary information already available contain. On the one hand, these documents must allow inspection, both by ASPCAT technicians and by municipal technicians and/or other institutions in charge of carrying out these tasks. On the other hand, they must serve to support all the agents involved in the management and control of these low-risk facilities. We present the documentation generated so far. We are aware that it is not completely finished and we hope that this CoP will have the necessary continuity to finalize these documents and, if possible, extend them to other low-risk facilities. We hope this will help improve the hygienic-sanitary status of facilities considered low risk and reduce outbreaks and cases of legionellosis which, in recent years, have been found to be the main causes of this disease in our territory

Instal·lacions de baix risc de proliferació i dispersió de legionel·la: anàlisi de circuits i eines de control [part 1]

Legionel·la; Control oficial; Seguretat ambientalLegionela; Control oficial; Seguridad ambientalLegionella; Official control; Environmental securityLa legionel·losi és una malaltia d’origen ambiental causada per un bacteri anomenat Legionella. Aquest bacteri viu a l’aigua i pot colonitzar i créixer en instal·lacions que utilitzen aigua i que són susceptibles de generar aerosols si les condicions higienicosanitàries no són les adequades. Aquestes instal·lacions podrien ser la causa de brots epidèmics de legionel·losi o bé de casos aïllats. Les instal·lacions de baix risc (IBR), com ara els sistemes de reg per aspersió, les fonts ornamentals, els equips de neteja viària, els nebulitzadors alimentaris i de terrasses, etc., poden ser la causa dels brots comunitaris si no es prenen les mesures de control preventiu adients. La inspecció sanitària, el control i el seguiment d’aquestes instal·lacions corresponen als ajuntaments. Malgrat l’àmplia informació que hi ha respecte al tema, detectem que ens manca una definició tècnica en aquest tipus d’instal·lacions, la qual cosa genera confusió a l’hora de determinar quins són els paràmetres que s’han de requerir en el moment d’avaluar i inspeccionar aquestes instal·lacions. Per tant, vam decidir que, per tal de facilitar la tasca d’inspecció tant a tècnics municipals i de la DIBA com als de l’ASPCAT en els casos en què s’aborden inspeccions d’instal·lacions de baix risc per investigar brots comunitaris de legionel·losi, calia engegar aquesta comunitat de pràctica (CoP) amb la finalitat de definir i consensuar quins havien de ser els paràmetres de referència i les periodicitats mínimes de revisió i manteniment a què havien d’estar subjectes els diferents tipus d’instal·lacions.La legionelosis es una enfermedad de origen ambiental causada por una bacteria llamada Legionella. Esta bacteria vive en el agua y puede colonizar y crecer en instalaciones que utilizan agua y que son susceptibles de generar aerosoles si las condiciones higiénico-sanitarias no son las adecuadas. Estas instalaciones podrían ser la causa de brotes epidémicos de legionelosis o de casos aislados. Las instalaciones de bajo riesgo (IBR), como los sistemas de riego por aspersión, las fuentes ornamentales, los equipos de limpieza viaria, los nebulizadores alimentarios y de terrazas, etc., pueden ser la causa de los brotes comunitarios si no se toman las medidas de control preventivo adecuadas. La inspección sanitaria, control y seguimiento de estas instalaciones corresponden a los ayuntamientos. A pesar de la amplia información que existe respecto al tema, detectamos que nos falta una definición técnica en este tipo de instalaciones, lo que genera confusión a la hora de determinar cuáles son los parámetros que deben requerirse en el momento de evaluar e inspeccionar estas instalaciones. Por tanto, decidimos que, para facilitar la labor de inspección tanto a técnicos municipales y de la DIBA como a los de la ASPCAT en los casos en que se abordan inspecciones de instalaciones de bajo riesgo para investigar brotes comunitarios de legionelosis, había que poner en marcha esta comunidad de práctica (CoP) con el fin de definir y consensuar cuáles debían ser los parámetros de referencia y las periodicidades mínimas de revisión y mantenimiento a las que debían estar sujetos los diferentes tipos de instalacionesLegionellosis is an environmental disease caused by a bacteria called Legionella. This bacteria lives in water and can colonize and grow in facilities that use water and are susceptible to generating aerosols if the hygienic-sanitary conditions are not adequate. These facilities could be the cause of epidemic outbreaks of legionellosis or isolated cases. Low risk facilities (IBR), such as sprinkler irrigation systems, ornamental fountains, street cleaning equipment, food and terrace misters, etc., can be the cause of community outbreaks if appropriate measures are not taken. appropriate preventive control measures. The health inspection, control and monitoring of these facilities corresponds to the town councils. Despite the extensive information that exists on the subject, we detected that we lack a technical definition in this type of facilities, which generates confusion when determining what parameters should be required when evaluating and inspecting these facilities. . Therefore, we decided that, to facilitate the inspection work for both municipal and DIBA technicians and those of ASPCAT in cases where inspections of low-risk facilities are carried out to investigate community outbreaks of legionellosis, it was necessary to put in place This community of practice (CoP) was launched in order to define and agree on what the reference parameters should be and the minimum review and maintenance periodicities to which the different types of facilities should be subject

Impact of a multidisciplinary team for the management of thrombotic microangiopathy.

BACKGROUND:Thrombotic microangiopathy (TMA) is an important complication associated with several diseases that are rare and life-threatening. TMA is common to thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TTP is defined by a severe deficiency of ADAMTS13, and early treatment is associated with good prognosis. The diagnosis of HUS can be difficult due to the potential multiple etiologies, and the best treatment option in most cases is not well-established yet. The implementation of a multidisciplinary team (MDT) could decrease the time to diagnosis and treatment for HUS and may improve the outcomes of these patients. OBJECTIVE:To determine the impact of MDT on morbidity and mortality [death or chronic renal replacement therapy (CRRT) requirements], incidence and response time [(RT) defined as the period between hospital admission and the first day of direct therapy administration], length of stay at an intensive care unit (ICU-LOS) and total hospitalization (T-LOS) were also assessed. METHODS:We compared a pre-MDT implementation period (from January/2008 to May/2016) versus post-MDT period (from May/2016 to December/2016). The screening TMA diagnosis was made according the following criteria: hemolytic anemia, thrombocytopenia and acute renal damage and without ADAMTS13 deficiency. An online chat was implemented to provide instant medical information. RESULTS:Twenty-eight patients were included. The incidence changed from 2.3 cases/pre-MDT: (all cases: n = 18) to 10 cases/year post-MDT (all cases: n = 10). Two patients died in pre-MDT and post- MDT (11% versus 20%, P = 0.60). From pre-MDT, the number of patients who required CRRT by post-MDT decreased from 7 (39%) to 0, P = 0.03. Similarly, RT, ICU-LOS and T-LOS [median(p25-p75)] decreased from 10 (2-12) days to 0.5 (0-1.5) days, P = 0.04, from 16 (9-30) days to 10 (4-13) days, P = 0.01 and from 33 (22-53) days to 16 (12-32) days, P < 0.01, respectively. CONCLUSION:MDT implementation was associated with a greater number of patients who meet TMA criteria. A decrease in the RT and T-LOS periods were observed and associated with better outcomes in these patients

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

International audienceBackground: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates