Principales cambios en las Recomendaciones para la Resucitación del Consejo Europeo de Resucitación (ERC) 2015.

RESUMEN: Recientemente se han publicado las nuevas guías referentes a la Reanimación Cardiopulmonar (RCP) por parte del European Resuscitation Council (ERC). El mismo día, el Consejo Español de Resucitación Cardiopulmonar (CERCP) emitía una declaración oficial para manifestar su adhesión a estas recomendaciones. Esta misma declaración menciona “la necesidad de la aplicación ajustada de estas recomendaciones europeas, tanto en el ámbito asistencial como en el de la formación”. Aunque se mantienen la mayoría de las recomendaciones publicadas en el año 2010, es preciso conocer estos cambios para ajustarse a los nuevos conocimientos científicos. Para ello, este documento pretende resumir los principales cambios respecto a las recomendaciones anteriores con el objetivo de proporcionar una primera aproximación a los profesionales sanitarios.ABSTRACT: Recently, the new guidelines about cardiopulmonary resuscitation were published by the European Resuscitation Council (ERC). The same day, the Consejo Español de Resucitación Cardiopulmonar (CERCP) gave an announcement to declare the adhesion to these guidelines. This announcement brings up “the requirement to apply these European suggestions, both in the care services environment and in the formation environment”. Although most of the suggestions have had no changes with those suggestions published in 2010, the knowledge of these changes is needed to accommodate to the new knowledge. For this reason, this document pretends summarise the main changes in relation to the previous guidelines with the purpose to provide a first approach for healthcare professionals

A blood microRNA classifier for the prediction of ICU mortality in COVID-19 patients: a multicenter validation study

Background: The identification of critically ill COVID-19 patients at risk of fatal outcomes remains a challenge. Here, we first validated candidate microRNAs (miRNAs) as biomarkers for clinical decision-making in critically ill patients. Second, we constructed a blood miRNA classifier for the early prediction of adverse outcomes in the ICU. Methods: This was a multicenter, observational and retrospective/prospective study including 503 critically ill patients admitted to the ICU from 19 hospitals. qPCR assays were performed in plasma samples collected within the first 48 h upon admission. A 16-miRNA panel was designed based on recently published data from our group. Results: Nine miRNAs were validated as biomarkers of all-cause in-ICU mortality in the independent cohort of critically ill patients (FDR < 0.05). Cox regression analysis revealed that low expression levels of eight miRNAs were associated with a higher risk of death (HR from 1.56 to 2.61). LASSO regression for variable selection was used to construct a miRNA classifier. A 4-blood miRNA signature composed of miR-16-5p, miR-192-5p, miR-323a-3p and miR-451a predicts the risk of all-cause in-ICU mortality (HR 2.5). Kaplan‒Meier analysis confirmed these findings. The miRNA signature provides a significant increase in the prognostic capacity of conventional scores, APACHE-II (C-index 0.71, DeLong test p-value 0.055) and SOFA (C-index 0.67, DeLong test p-value 0.001), and a risk model based on clinical predictors (C-index 0.74, DeLong test-p-value 0.035). For 28-day and 90-day mortality, the classifier also improved the prognostic value of APACHE-II, SOFA and the clinical model. The association between the classifier and mortality persisted even after multivariable adjustment. The functional analysis reported biological pathways involved in SARS-CoV infection and inflammatory, fibrotic and transcriptional pathways. Conclusions: A blood miRNA classifier improves the early prediction of fatal outcomes in critically ill COVID-19 patients.11 página

Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic : a matched analysis

The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with COVID-19-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior non-invasive respiratory support on outcomes. This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICU) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of intensive care unit (ICU) admission. Propensity score (PS) matching was used to achieve balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different timepoint (48 h from ICU admission) for early and delayed intubation. Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After PS matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%, p =0.01), ICU mortality (25.7% versus 36.1%, p=0.007) and 90-day mortality (30.9% versus 40.2%, p=0.02) when compared to the early intubation group. Very similar findings were observed when we used a 48-hour timepoint for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth wave, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (n=294) who were intubated earlier. The subgroup of patients undergoing NIV (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h. In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received high-flow nasal cannul

Prognostic implications of comorbidity patterns in critically ill COVID-19 patients: A multicenter, observational study

Background The clinical heterogeneity of COVID-19 suggests the existence of different phenotypes with prognostic implications. We aimed to analyze comorbidity patterns in critically ill COVID-19 patients and assess their impact on in-hospital outcomes, response to treatment and sequelae. Methods Multicenter prospective/retrospective observational study in intensive care units of 55 Spanish hospitals. 5866 PCR-confirmed COVID-19 patients had comorbidities recorded at hospital admission; clinical and biological parameters, in-hospital procedures and complications throughout the stay; and, clinical complications, persistent symptoms and sequelae at 3 and 6 months. Findings Latent class analysis identified 3 phenotypes using training and test subcohorts: low-morbidity (n=3385; 58%), younger and with few comorbidities; high-morbidity (n=2074; 35%), with high comorbid burden; and renal-morbidity (n=407; 7%), with chronic kidney disease (CKD), high comorbidity burden and the worst oxygenation profile. Renal-morbidity and high-morbidity had more in-hospital complications and higher mortality risk than low-morbidity (adjusted HR (95% CI): 1.57 (1.34-1.84) and 1.16 (1.05-1.28), respectively). Corticosteroids, but not tocilizumab, were associated with lower mortality risk (HR (95% CI) 0.76 (0.63-0.93)), especially in renal-morbidity and high-morbidity. Renal-morbidity and high-morbidity showed the worst lung function throughout the follow-up, with renal-morbidity having the highest risk of infectious complications (6%), emergency visits (29%) or hospital readmissions (14%) at 6 months (p<0.01). Interpretation Comorbidity-based phenotypes were identified and associated with different expression of in-hospital complications, mortality, treatment response, and sequelae, with CKD playing a major role. This could help clinicians in day-to-day decision making including the management of post-discharge COVID-19 sequelae. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd

Effect of viral storm in patients admitted to intensive care units with severe COVID-19 in Spain: a multicentre, prospective, cohort study

Background: The contribution of the virus to the pathogenesis of severe COVID-19 is still unclear. We aimed to evaluate associations between viral RNA load in plasma and host response, complications, and deaths in critically ill patients with COVID-19. Methods: We did a prospective cohort study across 23 hospitals in Spain. We included patients aged 18 years or older with laboratory-confirmed SARS-CoV-2 infection who were admitted to an intensive care unit between March 16, 2020, and Feb 27, 2021. RNA of the SARS-CoV-2 nucleocapsid region 1 (N1) was quantified in plasma samples collected from patients in the first 48 h following admission, using digital PCR. Patients were grouped on the basis of N1 quantity: VIR-N1-Zero ([removed]2747 N1 copies per mL). The primary outcome was all-cause death within 90 days after admission. We evaluated odds ratios (ORs) for the primary outcome between groups using a logistic regression analysis. Findings: 1068 patients met the inclusion criteria, of whom 117 had insufficient plasma samples and 115 had key information missing. 836 patients were included in the analysis, of whom 403 (48%) were in the VIR-N1-Low group, 283 (34%) were in the VIR-N1-Storm group, and 150 (18%) were in the VIR-N1-Zero group. Overall, patients in the VIR-N1-Storm group had the most severe disease: 266 (94%) of 283 patients received invasive mechanical ventilation (IMV), 116 (41%) developed acute kidney injury, 180 (65%) had secondary infections, and 148 (52%) died within 90 days. Patients in the VIR-N1-Zero group had the least severe disease: 81 (54%) of 150 received IMV, 34 (23%) developed acute kidney injury, 47 (32%) had secondary infections, and 26 (17%) died within 90 days (OR for death 0·30, 95% CI 0·16–0·55; p<0·0001, compared with the VIR-N1-Storm group). 106 (26%) of 403 patients in the VIR-N1-Low group died within 90 days (OR for death 0·39, 95% CI 0·26–0·57; p[removed]11 página

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Factores pronósticos del traumatismo torácico grave en población mayor de 65 años, 1991-2012

RESUMEN: En los últimos años se ha producido un aumento de la longevidad y de la calidad de vida en edades cada vez más avanzadas. Las personas de mayor edad presentan una elevada actividad física y una gran independencia funcional. De forma paralela, se ha observado un incremento de la atención sanitaria como consecuencia de sufrir un traumatismo en esta población. Por otra parte, la población de edad avanzada posee características especiales que deben ser tenidas en cuenta tanto en la valoración como en el manejo de estas personas en el contexto de la enfermedad traumática. Sin embargo, los factores pronósticos de gravedad y mortalidad no se conocen con exactitud en esta población. El objetivo de este estudio es conocer los factores pronósticos asociados a una mayor mortalidad durante la estancia en una Unidad de Cuidados Intensivos de aquellas personas con edad igual o mayor a 65 años que ingresan con diagnóstico de traumatismo torácico. Para ello, se realizó un estudio descriptivo retrospectivo sobre la población de la Comunidad Autónoma de Cantabria durante los años 1991 a 2012, analizando variables relacionadas con la valoración inicial tras el traumatismo y determinados parámetros cuyo valor se obtiene en las primeras 24 horas de estancia en la unidad.ABSTRACT: In recent years there has been an increase in longevity and quality of life in increasingly advanced ages. Elderly people have a high physical activity and a high functional independence. In parallel form, there has been an increase in health care as a result of suffering a trauma in this population. Furthermore, the elderly population has special characteristics that must be taken into account in the assessment and management of these people in the context of traumatic disease. However, the prognostic factors of severity and mortality is not known exactly in this population. The aim of this study was to determine the prognostic factors associated with increased mortality during the stay in an intensive care unit for those with age greater than or equal to 65 years admitted with diagnosis of chest trauma. For this reason, a retrospective study on the population of the Autonomous Community of Cantabria was made during the years 1991 to 2012, analyzing related to the initial assessment following trauma and certain parameters variables whose value is obtained in the first 24 hours of stay in unit

Elección de fluidos en el periodo perioperatorio del trasplante renal

El suero salino normal (SSN) ha sido clásicamente el fluido de resucitación elegido en el periodo perioperatorio del trasplante renal frente a aquellas soluciones balanceadas con potasio. Sin embargo, los problemas derivados de la hipercloremia desencadenada por la infusión de SSN han llevado a la realización de estudios que comparaban esta solución con los fluidos equilibrados. Mediante la presente revisión narrativa se deduce que el uso de cristaloides balanceados con contenido de potasio en su formulación, en el perioperatorio de trasplante renal, puede considerarse seguro. Estas soluciones no provocan una alteración del potasio sérico mayor que la provocada por el SSN y mantienen mejor el equilibrio ácido-base en estos enfermos