Utilidad del monitoreo multimodal en niños con amebiasis cerebral en terapia intensiva. Relato de un caso clínico

Acanthamoeba spp. and Balamuthia mandrillaris are causative agents of granulomatous amebic encephalitis (GAE), while Naegleria fowleri causes primary amebic meningoencephalitis (PAM). PAM is an acute infection lasting a few days, whereas GAE is a chronic or subacute infection that can last up to several months. In the present case we report a 10-year-old girl with amebic encephalitis symptomatology, evolution, medical-surgical intervention, specific therapy, and patient outcome. Cerebral involvement continues to have high mortality in pediatric patients, despite guided therapy through multimodal monitoring in pediatric intensive care, however noninvasive methods during cerebral evaluation play an important role in optimizing cerebral hemodynamics at the patient's bedside. We conclude that this case demonstrates the usefulness of multimodal monitoring, where we used intraparenchymal ICP sensor, conventional Transcranial Doppler, NIRS, color coded transcranial doppler, optic nerve sheath measurement, DVNO/DTO ratio, pupillometry, and EEG that helped to make appropriate decisions during the clinical evolution of our patient, which would help us to make an early diagnosis and avoid delays in interventions.Acanthamoeba spp. y Balamuthia mandrillaris son agentes causantes de encefalitis amebiana granulomatosa (GAE), mientras que Naegleria fowleri causa meningoencefalitis amebiana primaria (PAM). La PAM es una infección aguda que dura unos pocos días, mientras que la GAE es una infección crónica o subaguda que puede durar hasta varios meses. En el presente caso reportamos a una niña de 10 años con sintomatología encefalitis amebiana, evolución, intervención médico-quirúrgicas, terapia específica y desenlace de la paciente. La afectación cerebral sigue teniendo alta mortalidad en los pacientes pediátricos, a pesar de la terapéutica guiada a través del monitoreo multimodal en cuidados intensivos pediátricos, sin embargo, los métodos no invasivos durante la evaluación cerebral, tiene un papel importante para optimizar la hemodinamia cerebral a la cama del paciente. Concluimos que este caso demuestra la utilidad del monitoreo multimodal, en donde utilizamos sensor PIC intraparenquimal, Doppler transcraneal convencional, Dúplex transcraneal codificado en color, NIRS, medición DVNO, ratio DVNO/DTO, pupilometría, y EEG que ayudó a tomar decisiones adecuadas durante la evolución clínica de nuestro paciente, que nos ayudaría hacer un diagnóstico precoz y evitar demoras en las intervenciones

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

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