Inotrópicos en el postoperatorio de cirugía cardiovascular: estudio de corte transversal

Introducción: Los inotrópicos, fármacos de uso frecuente en la unidad de cuidado intensivo, se emplean con el fin de mantener la perfusión tisular en los diferentes estados de choque mientras se resuelve la etiología del mismo. Los pacientes programados para cirugía cardiovascular son un subgrupo que con frecuencia requiere tratamiento con estos fármacos en el postoperatorio. Objetivo: Describir la frecuencia y el tipo de fármacos usados para el soporte hemodinámico de pacientes en el postoperatorio de cirugía cardiovascular electiva en la Clínica Fundadores, Bogotá, DC. Métodos: Estudio de corte trasversal, en el que se incluyeron todos los pacientes que ingresaron en la unidad de cuidado intensivo sin requerimiento de soporte hemodinámico farmacológico entre octubre de 2010 y diciembre de 2011 en postoperatorio de cirugía cardiaca. Se extrajeron de las historias clínicas electrónicas la edad, el sexo, el puntaje EuroSCORE, el diagnóstico prequirúrgico, el uso de circulación extracorpórea, el uso de fármacos vasoactivos, los días de estancia en la unidad de cuidado intensivo y la mortalidad. Resultados: Se encontraron 150 registros de cirugía cardiovascular con una edad media de 62,8 años (DE 10,5), de los cuales 97 (64,6%) eran hombres. Se encontraron 22 (15%) casos con EuroSCORE en riesgo alto, 93 (62%) en riesgo moderado y 35 (23%) en riesgo bajo. Los diagnósticos prequirúrgicos incluyeron enfermedad coronaria en 105 (70%) pacientes, valvulopatías en 29 (19%), cardiopatía isquémica y valvular en 9 (6%) y comunicación interauricular en 6 (4%). En 57 (38%) casos se empleó circulación extracorpórea con un tiempo medio (RIQ) de 92 (73-114) minutos, de quienes 55 se operaron con clamp aórtico, con un tiempo medio (RIQ) de 75 (52-90) minutos. En 78 (52%) pacientes se utilizó uno o más fármacos vasoactivos, siendo la adrenalina el de mayor frecuencia en 41 (27%) casos. Los pacientes que necesitaron inodilatadores fueron 22 (15%) y recibieron dobutamina. La mediana (RIQ) de estancia en la unidad de cuidados intensivos fue de 3 (2-4) días y murieron 6 (4,7%) pacientes. Conclusión: En casi la mitad de los pacientes en postoperatorio de cirugía cardiovascular se utilizó un agente inotrópico, de los cuales la adrenalina fue la más frecuente, seguida de la norepinefrina; el inodilatador utilizado fue la dobutamina. No se utilizaron inotrópicos sensibilizadores del calcio y en baja frecuencia inhibidores de la fosfodiesterasa III con resultados similares en cuanto a estancia en la unidad de cuidados intensivos y mortalidad respecto a estudios en otras poblaciones

Outbreak of CA-MRSA in patients with neuro-development disorders requiring ICU admission

INTRODUCTION. CA-MRSA in Latin America has become an emergent microorganism causing severe infections requiring ICU admission. This epidemic outbreak is especially present in a group of patients bearing characteristics associated with hospital care. OBJECTIVES. Description of the epidemiological characteristics related to genotyping, phenotyping, and management of a CA-MRSA outbreak in patients treated at an ICU in Bogota, Colombia. METHODS. Case studies and controls. RESULTS. Of 100 persons treated at a healthcare institution for neurodevelopmental diseases, 50 consulted to emergency departments between September 2008 and January 2009 with skin infections (n:15) arthritis (n:2) or pneumonia (n:1). In 15 of these patients CAMRSA was isolated, 53 % (8) in blood. Identified through genotyping such as SSCmec Ivc clone USA300, with lukF-PV/tukS-PV genes seq, sek and bsaB. 100 % were PVL positive. 10 (73 %) patients evidenced neuropsychiatric alterations with behavioral trauma such as coprophagy, shared use of hygiene elements, and recurrent skin lesions. 1 with pneumonia and 2 with skin infections required ICU admission. CA-MRSA was not documented in cultures of physicians, nurses, and therapists in charge of patient care at the institute. Decolonization of patients with CA-MRSA was conducted with nasal Mupirocin and Chlorhexidine baths for 7 days, and contact isolation was instaured. Global mortality was 20 % being lowest in the group that received empirical treatment with Vancomycin, compared to those that used Oxacillin-Clindamycin (33.3 vs. 66.6 %). CONCLUSIONS. USA300 is a potential cause of CA-MRSA outbreaks requiring ICU admission. REFERENCE(S). 1. Vandenesch F, et al. Emerg Infect Dis. 2003;9:978–84. 2. Campbell K, et al. J Clin Microbiol. 2004;50–4053. 3. Wagenlehner F, et al. J Hosp Infect. 2007;67:114–20

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection.

INTRODUCTION Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial. METHODS Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry. RESULTS Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. CONCLUSIONS Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections

Infecciones del tracto urinario bajo en adultos y embarazadas: consenso para el manejo empírico

Introducción: La infección no complicada del tracto urinario bajo y la bacteriuria asintomática son causas frecuentes de consulta médica ambulatoria y en el servicio de urgencias en Colombia y el mundo. La falta de pautas y consenso para el manejo, así como la emergencia de resistencia a las múltiples opciones terapéuticas disponibles en los uropatógenos provenientes de la comunidad, hacen necesario elaborar unas recomendaciones que orienten al clínico sobre el abordaje óptimo de estas entidades. Objetivo: Definir un consenso sobre el manejo empírico de la bacteriuria asintomática y la infección del tracto urinario (ITU) bajo en adultos y mujeres embarazadas en Colombia. Metodología: Se lleva a cabo una metodología de consenso con expertos en urología, infectología, medicina interna, ginecología y microbiología basada en la revisión de las referencias bibliográficas disponibles en los términos de búsqueda relacionados, haciendo énfasis en estudios locales. Resultados: Se elaboró un algoritmo de manejo para el tratamiento empírico de la ITU baja no complicada en adultos con antisépticos urinarios como nitrofurantoína y fosfomicina trometamol como primera línea, con recomendaciones terapéuticas específicas para el tratamiento de la bacteriuria asintomática en mujeres embarazadas. Adicionalmente, se formuló un algoritmo de decisión para el procesamiento de cultivos de orina. La recurrencia o recaída frecuente justifica remisión a urología e infectología. Conclusiones: Se generan recomendaciones prácticas de fácil implementación en el diagnóstico y manejo de la ITU bajo en adultos y embarazadas, y de los casos donde es necesario tratar la bacteriuria asintomática, con opciones terapéuticas efectivas y de espectro reducido

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection

Introduction: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial. Methods: Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry. Results: Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections. associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections. \ua9 Copyright jointly held by Springer and ESICM 2010

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p &lt; 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p &lt; 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p &lt; 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease