The Role Of Omega-3 Polyunsaturated Fatty Acids In The Treatment Of Patients With Acute Respiratory Distress Syndrome: A Clinical Review

Acute respiratory distress syndrome (ARDS) is defined as the acute onset of noncardiogenic edema and subsequent gas-exchange impairment due to a severe inflammatory process. Recent report on the prognostic value of eicosanoids in patients with ARDS suggests that modulating the inflammatory response through the use of polyunsaturated fatty acids may be a useful strategy for ARDS treatment. The use of enteral diets enriched with eicosapentaenoic acid (EPA) and gamma-linolenic acid (GLA) has reported promising results, showing an improvement in respiratory variables and haemodynamics. However, the interpretation of the studies is limited by their heterogeneity and methodology and the effect of omega-3 fatty acid-enriched lipid emulsion or enteral diets on patients with ARDS remains unclear. Therefore, the routine use of omega-3 fatty acid-enriched nutrition cannot be recommended and further large, homogeneous, and high-quality clinical trials need to be conducted to clarify the effectiveness of omega-3 polyunsaturated fatty acids

Surgical site infection in critically ill patients with secondary and tertiary peritonitis: epidemiology, microbiology and influence in outcomes

Background: Surgical site infection (SSI) remains a significant problem in the postoperative period that can negatively affect clinical outcomes. Microbiology findings are typically similar to other nosocomial infections, with differences dependent on microbiology selection due to antibiotic pressure or the resident flora. However, this is poorly understood in the critical care setting. We therefore aimed to assess the incidence, epidemiology and microbiology of SSI and its association with outcomes in patients with severe peritonitis in the intensive care unit (ICU). Methods: We prospectively studied 305 consecutive patients admitted to our surgical ICU from 2010 to 2014 with a diagnosis of secondary or tertiary peritonitis. We collected the following data: SSI diagnosis, demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II score, type of surgery, microbiology, antibiotic treatment and outcomes. Microbiological sampling was done by means of swabs. Results: We identified 269 episodes of SSI in 162 patients (53.1 %) aged 64.4 +/- 14.3 years, of which 200 episodes occurred in men (64.6 %). The mean APACHE II and SAPS II scores were 19.7 +/- 7.8 and 36.5 +/- 16.1 respectively. The mean ICU and hospital stays were 19.8 +/- 24.8 and 21.7 +/- 30 days respectively. Pseudomonas spp. (n = 52, 19.3 %), Escherichia coli (n = 55, 20.4 %) and Candida spp. (n = 46, 17.1 %) were the most frequently isolated microorganisms, but gram-positive cocci (n = 80, 29.7 %) were also frequent. Microorganisms isolated from SSIs were associated with a higher incidence of antibiotic resistance (64.9 %) in ICU patients, but not with higher in-hospital mortality. However, patients who suffered from SSI had longer ICU admissions (odds ratio = 1.024, 95 % confidence interval 1.010-1.039, P = 0.001). Conclusions: The incidence of SSI in secondary or tertiary peritonitis requiring ICU admission is very high. Physicians may consider antibiotic-resistant pathogens, gram-positive cocci and fungi when choosing empiric antibiotic treatment for SSI, although more studies are needed to confirm our results due to the inherent limitations of the microbiological sampling with swabs performed in our research. The presence of SSI may be associated with prolonged ICU stays, but without any influence on overall mortality

Augmented renal clearance. An unnoticed relevant event

Paciente críticamente enfermo; Tasa de filtrado glomerularPacient críticament malalt; Taxa de filtrat glomerularCritically ill patient; Glomerular filtrate rateAugmented renal clearance (ARC) is a phenomenon that can lead to a therapeutic failure of those drugs of renal clearance. The purpose of the study was to ascertain the prevalence of ARC in the critically ill patient, to study the glomerular filtration rate (GFR) throughout the follow-up and analyze the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimation formula and measured GFR. Observational, prospective, multicenter study. ARC was defined as a creatinine clearance greater than 130 ml/min/1.73 m2. Eighteen hospitals were recruited. GFR measurements carried out twice weekly during a 2-month follow-up period. A total of 561 patients were included. ARC was found to have a non-negligible prevalence of 30%. More even, up to 10.7% already had ARC at intensive care unit (ICU) admission. No specific pattern of GFR was found during the follow-up. Patients in the ARC group were younger 56.5 (53.5–58.5) versus 66 (63.5–68.5) years than in the non-ARC group, p < 0.001. ICU mortality was lower in the ARC group, 6.9% versus 14.5%, p = 0.003. There was no concordance between the estimation of GFR by the CKD-EPI formula and GFR calculated from the 4-h urine. ARC is found in up to 30% of ICU patients, so renal removal drugs could be under dosed by up to 30%. And ARC is already detected on admission in 10%. It is a dynamic phenomenon without an established pattern that usually occurs in younger patients that can last for several weeks. And the CKD-EPI formula does not work to estimate the real creatinine clearance of these patients

Fluvial nutrient dynamics in a humanized landscape. Insights from a hierarchical perspective

Enviem correu als editors per informar-nos sobre la política de drets d'autorGlobal change driven by human activity is overimposed on the hierarchical structure of fluvial ecosystems, causing a myriad of effects on their physical template and hydrology as well as on the quantity and quality of the resources for stream biota. Global change operates at all scales within this hierarchy, but its effects on the ecology of fluvial ecosystems at any particular scale may be exacerbated or overridden by concomitant effects occurring at other scales. The resulting effects can have major ecological implications on both ecosystem services (namely, biogeochemical processes associated to energy and matter flow) and biodiversity (namely, community structure), which currently are issues of central concern in environmental management. In this paper we focus on a particular ecological attribute of fluvial ecosystems, the capacity to process and retain nutrients, and examine how physical and chemical alterations caused by human activities, occurring at different scales, may interact to affect this capacity. We illustrate these effects based on existing knowledge and highlight the key changes at different scales which can be susceptible of major effects.El cambio global derivado de la actividad humana se sobrepone a la estructura jerárquica de los ecosistemas fluviales, causando múltiples efectos sobre la estructura física, la hidrología, y la cantidad y calidad de los recursos para los organismos de los ríos. El cambio global opera sobre todos los niveles de esta jerarquía estructural, pero sus efectos sobre la ecología de los ecosistemas fluviales en cada nivel pueden ser exacerbados o anulados por efectos que ocurren a otros niveles. Los efectos resultantes tienen implicaciones ecológicas tanto en relación con los servicios de los ecosistemas (por ejemplo, los procesos biogeoquímicos asociados al flujo de energía y materia) y la biodiversidad (por ejemplo, la estructura biótica de las comunidades). Actualmente, estos temas son una preocupación central en la gestión ambiental. En este artículo nos centramos en un atributo ecológico concreto de los ecosistemas fluviales, la capacidad de procesar y retener nutrientes, y examinamos cómo alteraciones físicas y químicas causadas por la actividad humana, que tienen lugar a diferentes niveles espaciales, pueden incidir en esta capacidad biogeoquímica. Estos efectos son ilustrados en base al conocimiento existente y enfatizan los cambios clave a diferentes niveles que pueden ser susceptibles de estos efectos

A comparative limnological study of the Guadalhorce reservoirs system (Málaga,SE.Spain)

15 páginas ; 6 Figuras ; 2 TablasA partir de 10s muestreos efectuados durante el período de mezcla (marzo de 1988) y estratificación (setiembre de 1988) en 10s tres embalses del sistema Guadalhorce, se analizan sus diferencias fisicoquimicas y biológicas. Aunque 10s tres embalses presentan un contenido de sales disueltas relativamente alto, Conde de Guadalhorce es de aguas carbonatadas, mientras que en Guadalhorce son importantes 10s cloruros y Guadalteba se encuentra en una posición intermedia. En estos dos 61- timos embalses la presencia de cloruros determina la existencia de una haloclina muy marcada, que en el caso de Guadalhorce es permanente. Desde el punto de vista de sus características tróficas, Guadalteba y Guadalhorce son eutróficos, 10 que se refleja en la alta concentración de nutrientes y pigmentos, asi como por tener respiración y ETS elevados. Por el contrario, Conde de Guadalhorce puede considerarse como mesotrófico a partir de 10s mismos parámetros, además de permanecer con oxigeno en el hipolimnion durante todo el verano.This research has been supported by the Comisión Asesora de Investigación Científica y Técnica grant nª PB85-0166 and sponsored by the Dirección General de Obras Hidráulicas of the Ministry of Public AffairsPeer reviewe

Combined Effects of Leaf Litter Inputs and a Flood on Nutrient Retention in a Mediterranean Mountain Stream During Fall

This study examined the effect of increasing in-channel leaf standing stocks on hydrologic transient storage and nutrient retention in a Mediterranean mountain stream. A flood at the end of the leaf fall period provided the opportunity to examine the effect of abrupt removal of much of the leaf material. Twenty-one chloride additions were performed from October to December 2004. In 13 of these, we also added ammonium and phosphate to estimate nutrient uptake lengths and uptake velocities to assess nutrient retention. The one-dimensional transport with inflow and storage (OTIS) model was used to estimate transient water storage parameters. Although discharge remained constant during leaf fall, water residence time increased because of in-channel litter accumulation, as did nutrient uptake velocity. Flooding reduced leaf benthic standing stocks by 65% and dramatically altered hydraulic and nutrient retention properties of the channel. After recession, the stream rapidly recovered in terms of nutrient retention, especially for phosphate. Abrupt changes in discharge under flood conditions largely determined the variability in stream nutrient retention. However, leaf litter inputs played an important role in nutrient dynamics during constant flow. Because both the flood regime and the timing of leaf fall are being regionally altered by climate change, our results have implications for stream nutrient dynamics under climate change scenarios

Myasthenia Gravis Induced by Immune Checkpoint Inhibitors: An Emerging Neurotoxicity in Neuro-Oncology Practice: Case Series

Immunotherapy with immune checkpoint inhibitors (ICIs) have been reported to induce de novo or exacerbate pre-existing Myasthenia Gravis (MG). We present a single center case series of patients who developed an immune-related myasthenia gravis (irMG) related with ICIs. We performed a retrospective chart review of the electronic medical records between 1 September 2017 and 2022. We report the clinical features, presentation forms, diagnostic workflows, general management and outcomes of six patients who received ICIs for different solid organ malignancies and developed an irMG frequently overlapping with immune-related myocarditis and/or myositis. The aim of the article is to describe the clinical features, treatment and outcomes of this challenging and potentially life-threating syndrome, comparing our data with those described in the literature. Differences between irMG and classic MG are highlighted

Outcomes of COVID-19 Patients Admitted to the Intermediate Respiratory Care Unit: Non-Invasive Respiratory Therapy in a Sequential Protocol

The intermediate respiratory care units (IRCUs) have a pivotal role managing escalation and de-escalation between the general wards and the intensive care units (ICUs). Since the COVID-19 pandemic began, the early detection of patients that could improve on non-invasive respiratory therapies (NRTs) in IRCUs without invasive approaches is crucial to ensure proper medical management and optimize limiting ICU resources. The aim of this study was to assess factors associated with survival, ICU admission and intubation likelihood in COVID-19 patients admitted to IRCUs. Observational retrospective study in consecutive patients admitted to the IRCU of a tertiary hospital from March 2020 to April 2021. Inclusion criteria: hypoxemic respiratory failure (SpO(2) = 25 rpm with FiO(2) > 50% supplementary oxygen) due to acute COVID-19 infection. Demographic, comorbidities, clinical and analytical data, and medical and NRT data were collected at IRCU admission. Multivariate logistic regression models assessed factors associated with survival, ICU admission, and intubation. From 679 patients, 79 patients (12%) had an order to not do intubation. From the remaining 600 (88%), 81% survived, 41% needed ICU admission and 37% required intubation. In the IRCU, 51% required non-invasive ventilation (NIV group) and 49% did not (non-NIV group). Older age and lack of corticosteroid treatment were associated with higher mortality and intubation risk in the scheme, which could be more beneficial in severe forms. Initial NIV does not always mean worse outcomes

Days spent on non-invasive ventilation support: can it determine when to initiate VV- ECMO? Observational study in a cohort of Covid-19 patients

Background The study evaluates the impact of the time between commencing non-invasive ventilation (NIV) support and initiation of venovenous extracorporeal membrane oxygenation (VV-ECMO) in a cohort of critically ill patients with coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS).Methods Prospective observational study design in an intensive Care Unit (ICU) of a tertiary hospital in Barcelona (Spain). All patients requiring VV-ECMO support due to COVID-19 associated ARDS between March 2020 and January 2022 were analysed. Survival outcome was determined at 90 days after VV-ECMO initiation. Demographic data, comorbidities at ICU admission, RESP (respiratory ECMO survival prediction) score, antiviral and immunomodulatory treatments received, inflammatory biomarkers, the need for vasopressors, the thromboprophylaxis regimen received, and respiratory parameters including the length of intubation previous to ECMO and the length of each NIV support (high-flow nasal cannula, continuous positive airway pressure and bi-level positive airway pressure), were also collated in order to assess risk factors for day-90 mortality. The effect of the time lapse between NIV support and VV-ECMO on survival was evaluated using logistic regression and adjusting the association with all factors that were significant in the univariate analysis.Results Seventy-two patients finally received VV-ECMO support. At 90 days after commencing VV-ECMO 35 patients (48%) had died and 37 patients (52%) were alive. Multivariable analysis showed that at VV-ECMO initiation, age (p = 0.02), lactate (p = 0.001), and days from initiation of NIV support to starting VV-ECMO (p = 0.04) were all associated with day-90 mortality.Conclusions In our small cohort of VV-ECMO patients with COVID-19 associated ARDS, the time spent between initiation of NIV support and VV-ECMO (together with age and lactate) appeared to be a better predictor of mortality than the time between intubation and VV-ECMO

Predictive Factors of Piperacillin Exposure and the Impact on Target Attainment after Continuous Infusion Administration to Critically Ill Patients

Critically ill patients undergo significant pathophysiological changes that affect antibiotic pharmacokinetics. Piperacillin/tazobactam administered by continuous infusion (CI) improves pharmacokinetic/pharmacodynamic (PK/PD) target attainment. This study aimed to characterize piperacillin PK after CI administration of piperacillin/tazobactam in critically ill adult patients with preserved renal function and to determine the empirical optimal dosing regimen. A total of 218 piperacillin concentrations from 106 patients were simultaneously analyzed through the population PK approach. A two-compartment linear model best described the data. Creatinine clearance (CLCR) estimated by CKD-EPI was the covariate, the most predictive factor of piperacillin clearance (CL) interindividual variability. The mean (relative standard error) parameter estimates for the final model were: CL: 12.0 L/h (6.03%); central and peripheral compartment distribution volumes: 20.7 L (8.94%) and 62.4 L (50.80%), respectively; intercompartmental clearance: 4.8 L/h (26.4%). For the PK/PD target of 100% fT(>1xMIC), 12 g of piperacillin provide a probability of target attainment > 90% for MIC 100 mL/min. For 100% fT(>4xMIC), the highest dose (24 g/24 h) was not sufficient to ensure adequate exposure, except for MICs of 1 and 4 mg/L. Our model can be used as a support tool for initial dose guidance and during therapeutic drug monitoring