Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Análisis coste-efectividad en procesos que requieren ventilación mecánica: estudio de los GRD 475 y 483

Objetivo. Evaluar la relación coste-efectividad del tratamiento en procesos complejos predefinidos que precisan ventilación mecánica (VM). Diseño. Estudio de cohorte retrospectivo con análisis coste-efectividad y estimación del porcentaje de pacientes sometidos a cuidados potencialmente ineficientes (CPI). Ámbito. Unidad de Cuidados Intensivos (UCI) de un hospital general. Pacientes. Pacientes ingresados entre los años 1997 y 2001, asignados al alta hospitalaria a los GRD 475 (diagnósticos del sistema respiratorio con ventilación asistida) y 483 (traqueostomía excepto trastornos de la boca, laringe o faringe). Intervenciones. Ninguna. Variables de interés principales. Edad, sexo, gravedad (mediante APACHE II), estado crónico de salud, grupo patológico de base, estancia en UCI, estancia hospitalaria, duración de la VM, mortalidad hospitalaria predicha y observada. Estimación del coste-efectividad mediante cociente entre costes totales hospitalarios y años de vida ganados (avg). Porcentaje de pacientes sometidos a CPI, definido como pacientes con costes totales superiores al percentil 90 y destino exitus. Resultados. Se estudiaron 247 pacientes, 142 del GRD 475 y 105 del GRD 483. Los dos grupos poseían características similares, salvo mayor predominio de pacientes médicos, menor estancia y duración de VM en el GRD 475. El coste-efectividad fue favorable en todos los subgrupos estudiados, y mostró un incremento en ambos grupos de GRD según aumentaba la edad, la gravedad y la duración de la VM. La distribución del coste-efectividad por estado crónico de salud no mostró diferencias en el GRD 475, mientras que en el GRD 483 se producía un incremento del mismo según empeoraba el estado de salud. En el GRD 483 y grupo patológico de base cardiológico, se observaron los peores valores de coste-efectividad. El porcentaje de CPI fue del 7,0% en GRD 475 y del 5,4% en GRD 483. Conclusiones. El tratamiento de los pacientes críticos agrupables a los GRD 475 y 483, se ha mostrado coste-efectivo de forma global y en todos los subgrupos analizados. La estimación del coste-efectividad y del porcentaje de pacientes sometidos a CPI, en procesos con similar complejidad de la casuística, ofrece información médica y económica del funcionamiento de una UCI

Factores de riesgo cardiovascular en el ritmo circadiano del infarto agudo de miocardio

Introducción y objetivos. El objetivo de este trabajo es analizar la influencia de los factores de riesgo cardiovascular modificables en el ritmo circadiano del infarto agudo de miocardio. Pacientes y método. Análisis retrospectivo de 54.249 pacientes incluidos en la base de datos del proyecto ARIAM con diagnóstico de infarto agudo de miocardio. Se analizan las variables hora de inicio, edad, sexo, cardiopatía isquémica previa, estado en el momento del alta de la unidad coronaria, antecedentes familiares de cardiopatía isquémica, accidente cerebrovascular previo, hipertensión arterial, dislipemia, diabetes, tabaquismo y reinfarto. El análisis de ritmo se ha efectuado utilizando un test simple de igualdad de series basado en el análisis cosinor de múltiples sinusoides, eligiendo 3 armónicos (24,12 y 8 h) para su ajuste. Resultados. La hora de inicio del infarto muestra ritmo circadiano (p < 0,01) con pico a las 10,07 y valle a las 4,46 h. Todos los subgrupos categorizados por la presencia de las variables analizadas presentaron ritmo circadiano, con una curva ajustada de aspecto sinusoidal. Los pacientes con diabetes, reinfarto y tabaquismo muestran una curva sinusoidal de aspecto bimodal. Conclusiones. El infarto agudo de miocardio presenta ritmo circadiano. La diabetes, el tabaquismo y el reinfarto pueden modificar el ritmo habitual de aparición del infart

Absceso prostático como causa poco frecuente de shock séptico

El absceso prostático es una enfermedad poco frecuente, asociada generalmente a prostatitis, y cuyo diagnóstico puede retrasarse por lo inespecífico de la clínica. Es aún más raro que aparezcan complicaciones graves sistémicas. Será preciso un alto nivel de sospecha y la realización de técnicas de imagen para llegar a un diagnóstico de certeza. Presentamos el caso de un paciente en situación de shock séptico secundario a un absceso de próstata. Tras revisar la bibliografía comprobamos que son escasos los casos documentados de complicaciones sistémicas graves de este tipo de pacientes

Immunocompromised patients with acute respiratory distress syndrome: Secondary analysis of the LUNG SAFE database

Background: The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p &lt; 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p &lt; 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Immunocompromised patients with acute respiratory distress syndrome : Secondary analysis of the LUNG SAFE database

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study

Background: Current incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS). Methods: An international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared. Findings: 12 906 critically ill patients received mechanical ventilation and 34.9% with hypoxaemia and new infiltrates were enrolled, separated into ARDS (69.0%), unilateral infiltrate (22.7%) and congestive heart failure (CHF; 8.2%). The global hospital mortality was 38.6%. CHF patients had a mortality comparable to ARDS (44.1% versus 40.4%). Patients with unilateral-infiltrate had lower unadjusted mortality, but similar adjusted mortality compared to those with ARDS. The number of quadrants on chest imaging was associated with an increased risk of death. There was no difference in mortality comparing patients with unilateral-infiltrate and ARDS with only two quadrants involved. Interpretation: More than one-third of patients receiving mechanical ventilation have hypoxaemia and new infiltrates with a hospital mortality of 38.6%. Survival is dependent on the degree of pulmonary involvement whether or not ARDS criteria are reached