EFICACIA DE LA VARIABILIDAD DEL VOLUMEN SISTOLICO PARA GUIAR EL MANEJO DE LÍQUIDOS EN PACIENTES CON SEPSIS GRAVE Y CHOQUE SÉPTICO

El manejo de líquidos es la piedra angular en el tratamiento del estado de choque. Investigaciones recientes han demostrado que el uso agresivo de líquidos y la sobrecarga de volumen tienen consecuencias adversas incluso mortales. La variabilidad del volumen sistólico (VVS) es una técnica de monitoreo hemodinámico ampliamente recomendada para monitorizar y guiar la terapia de líquidos prediciendo que pacientes responderán a la administración intravenosa de volumen. Hasta el momento ningún estudio se ha realizado evaluando su eficacia en pacientes con sepsis grave o choque séptico

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Evaluación de la aplicación de ventilación de protección pulmonar en diferentes unidades de cuidados intensivos, hospital general Ecatepec las Américas

Se definió formalmente Síndrome de Distres Respiratorio Agudo (SDRA) según el consenso Americano – Europeo con los siguientes criterios: 1) Dificultad respiratoria grave de inicio agudo y súbito, 2) Infiltrados bilaterales en la radiografía de tórax frontal, 3) Ausencia de hipertensión de la aurícula izquierda (presión de capilar pulmonar inferior a 18 mmHg o sin signos clínicos de insuficiencia ventricular izquierda) e 4) Hipoxemia severa (determinada por la relación PaO2/FiO2 ≤200 mmHg)

ESTUDIO DE CORRELACIÓN ENTRE EL ÍNDICE DE COLAPSABILIDAD DE LA VENA CAVA INFERIOR Y LA VENA YUGULAR INTERNA EN PACIENTES AMBULATORIOS Y PACIENTES HOSPITALIZADOS DEL HOSPITAL GENERAL DE ECATEPEC “LAS AMERICAS”.

RESUMEN Las habilidades en la ultrasonografía en cuidados críticos permiten al Intensivista identificar pacientes que requieren una reanimación con volumen guiada a través de parámetros dinámicos. El índice de colapso de la vena yugular interna ha sido utilizado y correlacionado con valores hemodinámicos, demostrando una correlación positiva con la medición invasiva de PVC y volumen. En estudios previos se ha encontró que en donadores sanos existe una diferencia significativa antes y después de la perdida hemática inducida, es por esto que merece mayor estudio para valorar si es posible obtener otro parámetro de respuesta a volumen en pacientes bajo ventilación espontanea. Se realizó un estudio observacional, prospectivo, transversal y comparativo, con un total de 69 pacientes, divididos en tres grupos; pacientes sanos (31), pacientes hospitalizados sin datos de hipoperfusion (26) y pacientes hospitalizados con datos de hipoperfusion (12). Para el análisis estadístico se utilizó el programa SPSS versión 15. Para la realización de estadística analítica se realizó ANOVA de un factor para variables cuantitativas paramétricas y análisis de tres grupos. Para el análisis entre grupos se utilizó Pruebas Post hoc de comparación múltiple por Shaffe y Bonferroni. La correlación entre dos variables fue valorada usando el coeficiente de correlación de Pearson (r). El análisis de la asociación entre el índice de colapsabilidad de vena cava inferior y vena yugular interna demuestra una correlación positiva con un valor de .720 por Pearson, según Colton siendo esta una asociación moderada entre estas variables. Encontrando una r2. de .51 mostrando que el índice de colapsabilidad de la vena cava va a influir en un 51% del índice de colapsabilidad de la vena yugular interna. La media del índice de colapsabilidad de la Vena Cava inferior en nuestra población fue de 32.2% y media de colapsabilidad de vena yugular de 22.5%. Se encontró una diferencia estadísticamente significativa entre los grupos con una p> 0.001. Al realizar el análisis entre grupos encontramos una diferencia estadística 6 significativa para pacientes hospitalizados con datos de hipoperfusion contra cualquiera de los otros dos grupos. Existe una correlación positiva y asociación moderada entre el índice de colapso de la vena yugular interna y la vena cava inferior lo que nos sugiere que puede ser un sustituto adecuado para la valoración de la precarga y muy probablemente en la respuesta a volumen. El índice de colapso de la vena yugular interna es mayor en pacientes con datos de hipoperfusion en comparación con pacientes hospitalizados sin datos de hipoperfusion o en estado de choque como lo ya reportado por otros autores. La medición del índice de colapsabilidad de la vena yugular interna es una técnica simple y no invasiva que puede ser aplicada a la cabecera del paciente. La realización del índice de colapso de la vena yugular interna puede ser realizado por personal con poco o nulo entrenamiento en el uso de USG en el paciente crítico. Sin embargo hacen falta más estudios para poder obtener un punto de corte en el índice de colapsabilidad de la vena yugular interna y poder predecir la respuesta a volumen en un paciente determinado. La integración de este nuevo parámetro en la práctica clínica rutinaria requiere de ensayos aleatorios controlados en grandes grupos de pacientes

“PAPEL DEL ÍNDICE DE LA VENA CAVA INFERIOR COMO PRUEBA DE RESPUESTA A VOLUMEN EN GESTANTES DEL TERCER TRIMESTRE”

RESUMEN Introducción. Durante el embarazo hay importantes alteraciones hemodinámicas y la administración de líquidos en diferentes escenarios representa un verdadero reto. El diámetro de la vena cava inferior (VCI) es una medida estática relacionada con la precarga cardiaca y es un reflejo de la presión de la aurícula derecha. Los cambios dinámicos ventilatorios en la VCI como medida indirecta de respuesta a volumen han sido poco estudiados en embarazadas. Este trabajo se realizó con el objetivo de describir la incidencia de respuesta positiva a volumen evaluada por ultrasonido en embarazadas del tercer trimestre y evaluar la utilidad del índice de VCI como prueba de respuesta a volumen. Métodos. Estudio prospectivo, observacional y descriptivo. Se incluyeron 118 embarazadas. Se midió colapsabilidad de VCI en decúbito supino por ultrasonido y gasto cardiaco (GC) por USCOM® antes y después a elevación pasiva de piernas. Resultados. De 124 pacientes se excluyeron 5, quedando solo 118 pacientes, 33 (28%) fueron respondedoras a volumen por índice de VCI y 32 (27.1%) por cambio en GC (diferencia de 0.90%, IC95%: -11.0%-12.8%, X2<0.001, p=0.992). La media del porcentaje de cambio en GC en las respondedoras fue 29.1%, y -4.3% en las no respondedoras (p<0.001). Un diámetro de la VCI ≤53 mm tiene una sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de 83.5%, 72.1%, 64.1% y 90%, respectivamente para predecir respuesta positiva a volumen (área bajo la curva ROC: 0.86 [IC95%: 0.78-0.91], p<0.001). Conclusiones: Menos del 30% de las embarazadas en el tercer trimestre responden a volumen. El índice de VCI puede utilizarse como prueba de respuesta a volumen y un diámetro de la VCI ≤0.53 cm tiene un buen valor predictivo negativo para predecir respuesta a volumen en estas pacientes

Co-infection and ICU-acquired infection in COIVD-19 ICU patients: a secondary analysis of the UNITE-COVID data set

Background: The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients.Methods: This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson's Chi-squared and continuous variables by Mann-Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the "full" matching method.Results: Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO.Conclusions: In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids

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

The risk of COVID-19 death is much greater and age dependent with type I IFN autoantibodies

International audienceSignificance There is growing evidence that preexisting autoantibodies neutralizing type I interferons (IFNs) are strong determinants of life-threatening COVID-19 pneumonia. It is important to estimate their quantitative impact on COVID-19 mortality upon SARS-CoV-2 infection, by age and sex, as both the prevalence of these autoantibodies and the risk of COVID-19 death increase with age and are higher in men. Using an unvaccinated sample of 1,261 deceased patients and 34,159 individuals from the general population, we found that autoantibodies against type I IFNs strongly increased the SARS-CoV-2 infection fatality rate at all ages, in both men and women. Autoantibodies against type I IFNs are strong and common predictors of life-threatening COVID-19. Testing for these autoantibodies should be considered in the general population