Evaluación de la respuesta cardiovascular a dobutamina en la disfunción miocárdica asociada al shock séptico

Objetivos: 1. Evaluar la respuesta cardiovascular a dobutamina en la disfunción miocárdica secundaria a shock séptico. 2. Determinar si el análisis de la respuesta cronotrópica refleja la respuesta inotrópica.Objectius: 1. Avaluar la resposta cardiovascular a dobutamina en la disfunció miocàrdica secundària a shock sèptic. 2. Determinar si l'anàlisi de la resposta cronotròpica reflecteix la resposta inotròpica

Development and validation of a sample entropy-based method to identify complex patient-ventilator interactions during mechanical ventilation

Patient-ventilator asynchronies can be detected by close monitoring of ventilator screens by clinicians or through automated algorithms. However, detecting complex patient-ventilator interactions (CP-VI), consisting of changes in the respiratory rate and/or clusters of asynchronies, is a challenge. Sample Entropy (SE) of airway flow (SE-Flow) and airway pressure (SE-Paw) waveforms obtained from 27 critically ill patients was used to develop and validate an automated algorithm for detecting CP-VI. The algorithm’s performance was compared versus the gold standard (the ventilator’s waveform recordings for CP-VI were scored visually by three experts; Fleiss’ kappa = 0.90 (0.87–0.93)). A repeated holdout cross-validation procedure using the Matthews correlation coefficient (MCC) as a measure of effectiveness was used for optimization of different combinations of SE settings (embedding dimension, m, and tolerance value, r), derived SE features (mean and maximum values), and the thresholds of change (Th) from patient’s own baseline SE value. The most accurate results were obtained using the maximum values of SE-Flow (m = 2, r = 0.2, Th = 25%) and SE-Paw (m = 4, r = 0.2, Th = 30%) which report MCCs of 0.85 (0.78–0.86) and 0.78 (0.78–0.85), and accuracies of 0.93 (0.89–0.93) and 0.89 (0.89–0.93), respectively. This approach promises an improvement in the accurate detection of CP-VI, and future study of their clinical implications.This work was funded by projects PI16/01606, integrated in the Plan Nacional de R+D+I and co-funded by the ISCIII- Subdirección General de Evaluación y el Fondo Europeo de Desarrollo Regional (FEDER). RTC-2017-6193-1 (AEI/FEDER UE). CIBER Enfermedades Respiratorias, and Fundació Parc Taulí

Destino de los artículos rechazados en Medicina Intensiva en el período 2015-2017.

Introducción: Estudio retrospectivo sobre trabajos rechazados en Medicina Intensiva (MI) en 2015-2017 y publicados hasta 2019. Se analiza: tiempo de publicación, factor de impacto (FI), citas generadas y variables asociadas a la publicación. Resultados: De 344 originales y 263 cartas científicas, se rechazaron 420 (69,2%). Se publicaron después 205 (48,8%), y 66 de ellos generaron 180 citas. El FI de las revistas fue menor en 173 casos (84,4%). En 21 el número de citas válidas para FI fue mayor que el FI de MI. El origen del manuscrito OR 2,11 (IC 95% 1,29 – 3,46), la mujer como autora OR 1,58 (IC 95% 1,03-2,44), que estuviera en lengua inglesa OR 2,38 (IC 95% 1,41-4.0) y que el artículo hubiera sido pasado a revisores OR 1,71 (IC 95% 1,10-2,66). se asociaron con mayor tasa de publicación en revistas indexadas en PubMed. Conclusiones: Los artículos rechazados en MI tienen una tasa media de publicación en otras revistas, principalmente revistas con menos FI y generando menor número de citas que el FI de MI.pre-print269 K

Objective and subjective cognition in survivors of COVID-19 one year after ICU discharge : the role of demographic, clinical, and emotional factors

Altres ajuts: This research was also supported by CIBER -Consorcio Centro de Investigación Biomédica en Red- CB06/06/1097, Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación and Unión Europea - European Regional Development Fund.Intensive Care Unit (ICU) COVID-19 survivors may present long-term cognitive and emotional difficulties after hospital discharge. This study aims to characterize the neuropsychological dysfunction of COVID-19 survivors 12 months after ICU discharge, and to study whether the use of a measure of perceived cognitive deficit allows the detection of objective cognitive impairment. We also explore the relationship between demographic, clinical and emotional factors, and both objective and subjective cognitive deficits. Critically ill COVID-19 survivors from two medical ICUs underwent cognitive and emotional assessment one year after discharge. The perception of cognitive deficit and emotional state was screened through self-rated questionnaires (Perceived Deficits Questionnaire, Hospital Anxiety and Depression Scale and Davidson Trauma Scale), and a comprehensive neuropsychological evaluation was carried out. Demographic and clinical data from ICU admission were collected retrospectively. Out of eighty participants included in the final analysis, 31.3% were women, 61.3% received mechanical ventilation and the median age of patients was 60.73 years. Objective cognitive impairment was observed in 30% of COVID-19 survivors. The worst performance was detected in executive functions, processing speed and recognition memory. Almost one in three patients manifested cognitive complaints, and 22.5%, 26.3% and 27.5% reported anxiety, depression and post-traumatic stress disorder (PTSD) symptoms, respectively. No significant differences were found in the perception of cognitive deficit between patients with and without objective cognitive impairment. Gender and PTSD symptomatology were significantly associated with perceived cognitive deficit, and cognitive reserve with objective cognitive impairment. One-third of COVID-19 survivors suffered objective cognitive impairment with a frontal-subcortical dysfunction 12 months after ICU discharge. Emotional disturbances and perceived cognitive deficits were common. Female gender and PTSD symptoms emerged as predictive factors for perceiving worse cognitive performance. Cognitive reserve emerged as a protective factor for objective cognitive functioning. Trial registration : ClinicalTrials.gov Identifier: NCT04422444; June 9, 2021. The online version contains supplementary material available at 10.1186/s13054-023-04478-7

Evaluación no invasiva de la función cardiovascular en el paciente crítico mediante ecocardiografía /

Introducción: Esta tesis doctoral la conforman dos estudios que pretenden aportar más información acerca de la utilidad de la ecocardiografía en la evaluación de la función cardiovascular de los pacientes críticos. Estudio 1: " Predicción de la respuesta cardiovascular a volumen en pacientes críticos con actividad respiratoria espontánea mediante ecocardiografía" Objetivos: 1.Determinar si los cambios del volumen sistólico (VS) determinado mediante ecocardiografía, durante una maniobra de elevación pasiva de las piernas (MEP), predice la respuesta cardiovascular al aporte de volumen en pacientes críticos con actividad respiratoria espontánea. 2.Evaluar si los índices ecocardiográficos estáticos de estimación de precarga predicen la respuesta al aporte de volumen en esta población. Metodología: Se incluyeron pacientes críticos con actividad respiratoria espontánea a los que se administró volumen ante la presencia de hipoperfusión tisular. Medidas: período basal, durante una MEP, retorno posición inicial y tras 500 ml de suero fisiológico. Se recogieron variables clínicas, parámetros ecocardiográficos (ITVAo, VS, gasto cardíaco, fracción de eyección del ventrículo izquierdo (FEVI), ATDVIi, E/e'), la frecuencia cardíaca (FC) y presión arterial media (PAM)). Paciente respondedor: incremento de su VS ≥ 15%. Análisis estadístico: Mann-Whitney, Wilcoxon Rank Sum test, análisis de correlación de Spearman. Se compararon las áreas bajo las curvas ROC de los cambios en VS inducidos por la MEP con los estimadores de precarga (basales) mediante el test Hanley-McNeil. Resultados: Se incluyeron 24 pacientes. Trece pacientes fueron respondedores. El cambio en la ITVAo o en el VSi inducido por la MEP de un 12,5% o más predijo una respuesta a la administración de volumen con una sensibilidad del 77% y una especificidad del 100%. El ATDVIi y E/e' basal no difieren entre pacientes respondedores y no respondedores. Conclusiones: El estudio demuestra que la respuesta del VS a la MEP, determinada con ecocardiografía, es un buen predictor a la respuesta a volumen en pacientes con actividad respiratoria espontánea.Los parámetros ecocardiográficos estáticos de precarga cardíaca no son válidos para este propósito. Estudio 2: "Evaluación hemodinámica y ecocardiográfica de la respuesta cardiovascular a dobutamina en la disfunción miocárdica asociada al shock séptico" Objetivos: 1.Evaluar la respuesta inotrópica a dobutamina en pacientes con disfunción miocárdica asociada a shock séptico. Parámetros referencia: FEVI, VS indexado (VSi) determinado por termodilución (VSitd) y ecocardiografía (VSieco). 2. Deteminar si el análisis, a pie de cama, de la respuesta cronotrópica a dobutamina refleja la respuesta inotrópica. Metodología: Se incluyeron pacientes con shock séptico que recibieron dobutamina por disfunción miocárdica e hipoperfusión tisular persistente. Los pacientes se estudiaron antes y 30 minutos después de la administración de dobutamina (5 µg/kg/min). Se recogieron variables clínicas, ecocardiográficas (FEVI, VSieco, ITVAo, onda Sa) y hemodinámicas (FC, PAM). Paciente respondedor: incremento ≥ 15% del VSitd. Análisis estadístico: test de Student, curvas ROC,análisis correlación Pearson. Resultados: Se incluyeron 22 pacientes. Dobutamina produjo un incremento significativo en la FC (90 ± 17 vs 107 ± 20 lpm, p 0.0001), el VSitd (28.6 ± 10.3 vs 34.7 ± 13.8 ml/m2, p 0.005), la FEVI (34 ± 7 vs 47 ± 10 %, p 0.0001) y el VSieco (24.9 ± 5.9 vs 30 ± 7.4 ml/m2, p 0.01). : VSitd se incrementó ≥ 15% en 13 de los 21 pacientes (62%) monitorizados. Seis de los 22 pacientes (27%) incrementaron su FC 15%) ni la FC (≥ 10%). Se objetivó un incremento ≥ 10% en la FEVI en 17 de los 22 pacientes (77%) y un incremento ≥ 15% del VSieco en 12 de los 20 pacientes en los que se pudo obtener la ITVAo (60%). Los cambios en el VSieco (delta VSieco) se correlacionaron con los cambios en el VSitd (delta VSitd) (r=0,562, p 15 % del VSitd fue 0,308 + 0,147. Un valor de corte de 6 % de incremento de la FC tuvo una sensibilidad del 92%, una especificidad del 13%, un VPP del 63% y un VPN del 50% para detectar una respuesta inotrópica significativa. Conclusiones: Dobutamina mejora la función inotrópica en pacientes con shock séptico y disfunción miocárdica asociada. Por otro lado, el cambio de la FC no puede ser utilizado como un predictor, a pie de cama, del efecto inotrópico de dobutamina.Introduction: This doctoral thesis consists of two studies that aim to provide more information about the usefulness of echocardiography in evaluating the cardiovascular function of critically ill patients. Study 1: "Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity" Objectives: to test whether volume responsiveness can be predicted by the response of stroke volume (SV) measured with transthoracic echocardiography to passive leg raising in patients with spontaneous breathing activity. We also examined whether common echocardiographic indices of cardiac filling status are valuable to predict volume responsiveness in this patients. Methods: critically ill patients with spontaneously breathing activity considered for volume expansion were included. We measured the response of the echocardiographic SV to passive leg raising (PLR) and to saline infusion (500 ml over 15 min). The left ventricular end-diastolic area index (LVEDAi) and the ratio of mitral inflow E wave velocity to early diastolic mitral annulus velocity (E/e') were measured before and after saline infusion. Statistical analysis: Mann-Whitney test, Wilcoxon rank sum test, ROC curves for PLR-induced changes in SV index (SVi) (or in VTIAo), baseline LVEDAi and E/E' were compared in all patients using the Hanley-McNeil test. Results: A PLR-induced increase in SV of 12,5% or more predicted an increase in SV of 15% or more after volume expansion with a sensitivity of 77% and a specificity of 100%. Nether LVEDAi nor E/e' predicted volume responsiveness. Conclusions: in our critically ill patients with spontaneous breathing activity the response of echocardiographic SV to PLR was a good predictor of volume responsiveness. On the other hand, the common echocardiographic markers of cardiac filling status were not valuable for this purpose. Study 2: "Cardiovascular response to dobutamine in septic shock-induced myocardial dysfunction" Objectives: to assess inotropic response to the administration of dobutamine in septic shock patients who present myocardial dysfunction. To determine whether the chronotropic response to dobutamine reflects the inotropic response. Methods: We studied patients with septic shock-induced myocardial dysfunction (diagnosed by echocardiographic examination showing left ventricular ejection fraction (LVEF) ≤ 45%) for whom the attending physician decided to administer dobutamine (based on the persistence of inadequate tissue perfusion).Patients were assessed twice, just before the administration of dobutamine (5µg/kg/min) and 30 minutes later. Clinical variables and hemodynamic (heart rate (HR), SVitd) and echocardiographic parameters (LVEF, SViecho, Sa) were collected. Statistical analysis: Student test, ROC curves, Pearson's correlation. Results: Dobutamine infusion produced significant increases in HR (90 + 17 vs 107 + 20 bpm, p 0.0001), LVEF (34 + 7 vs 47 + 10 %, p 0.0001), SVIecho (24.9 + 5. 9 vs 30 + 7.4 ml/m2, p 0.01) and SVItd (28.6 + 10.3 vs 34.7 + 13.8 ml/m2, p 0.005). Dobutamine infusion increased LVEF 10% or more in 17 of 22 patients (77%) and an increase of 15% or more in 12 of the 20 patients (60%) in whom VSiecho was obtained. SVItd increased 15% or more in 13 of the 21 (62%) hemodynamically monitored patients. Two patients did not show a significant increase in HR (≥ 10%) and SVItd (≥ 15%). The changes in VSiecho were correlated with the changes in VSitd (r=0,562, p 0,05). The area under the ROC curve of the dobutamine-induce increase in HR to predict the inotropic response (≥ 15% in VSitd) was 0,308 ± 0,147. An increase of 6% o more in HR had a sensitivity of 92%, a specificity of 13%, a PPV of 63% and a NPV of 50% to detect a significant inotropic response. Conclusions: Dobutamine improves cardiovascular function in patients with septic shock-induced myocardial dysfunction. Furthermore, HR cannot be used as a marker, at bedside, of the inotropic response to dobutamine

Evaluación de la respuesta cardiovascular a dobutamina en la disfunción miocárdica asociada al shock séptico

Objetivos: 1. Evaluar la respuesta cardiovascular a dobutamina en la disfunción miocárdica secundaria a shock séptico. 2. Determinar si el análisis de la respuesta cronotrópica refleja la respuesta inotrópica.Objectius: 1. Avaluar la resposta cardiovascular a dobutamina en la disfunció miocàrdica secundària a shock sèptic. 2. Determinar si l'anàlisi de la resposta cronotròpica reflecteix la resposta inotròpica

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AimThe SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery.MethodsThis was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin.ResultsOverall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P ConclusionOne in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease