Medicina Intensiva最新文献

Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.

Objective

The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.

Design

Planned substudy of patients from ETHICUS II study.

Setting

12 Spanish ICU.

Patients or participants

Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months.

Interventions

Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death.

Main variables of interest

Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death.

Results

A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316(59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives.

Conclusions

The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity.

We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided.

Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.

Objective

To evaluate the impact of obesity on ICU mortality.

Design

Observational, retrospective, multicentre study.

Setting

Intensive Care Unit (ICU).

Patients

Adults patients admitted with COVID-19 and respiratory failure.

Interventions

None.

Primary variables of interest

Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. Body mass index (BMI) impact on ICU mortality was studied as (1) a continuous variable, (2) a categorical variable obesity/non-obesity, and (3) as categories defined a priori: underweight, normal, overweight, obesity and Class III obesity. The impact of obesity on mortality was assessed by multiple logistic regression and Smooth Restricted cubic (SRC) splines for Cox hazard regression.

Results

5,206 patients were included, 20 patients (0.4%) as underweight, 887(17.0%) as normal, 2390(46%) as overweight, 1672(32.1) as obese and 237(4.5%) as class III obesity. The obesity group patients (n = 1909) were younger (61 vs. 65 years, p < 0.001) and with lower severity scores APACHE II (13 [9–17] vs. 13[10−17, p < 0.01) than non-obese. Overall ICU mortality was 28.5% and not different for obese (28.9%) or non-obese (28.3%, p = 0.65). Only Class III obesity (OR = 2.19, 95%CI 1.44–3.34) was associated with ICU mortality in the multivariate and SRC analysis.

Conclusions

COVID-19 patients with a BMI > 40 are at high risk of poor outcomes in the ICU. An effective vaccination schedule and prolonged social distancing should be recommended.

Objective

To determine the prevalence of elevated mechanical power (MP) values (>17 J/min) used in routine clinical practice.

Design

Observational, descriptive, cross-sectional, analytical, multicenter, international study conducted on November 21, 2019, from 8:00 AM to 3:00 PM. NCT03936231.

Setting

One hundred thirty-three Critical Care Units.

Patients

Patients receiving invasive mechanical ventilation for any cause.

Interventions

None.

Main variables of interest

Mechanical power.

Results

A population of 372 patients was analyzed. PM was significantly higher in patients under pressure-controlled ventilation (PC) compared to volume-controlled ventilation (VC) (19.20 ± 8.44 J/min vs. 16.01 ± 6.88 J/min; p < 0.001), but the percentage of patients with PM > 17 J/min was not different (41% vs. 35%, respectively; p = 0.382). The best models according to AICcw expressing PM for patients in VC are described as follows: Surrogate Strain (Driving Pressure) + PEEP + Surrogate Strain Rate (PEEP/Flow Ratio) + Respiratory Rate. For patients in PC, it is defined as: Surrogate Strain (Expiratory Tidal Volume/PEEP) + PEEP + Surrogate Strain Rate (Surrogate Strain/Ti) + Respiratory Rate + Expiratory Tidal Volume + Ti.

Conclusions

A substantial proportion of mechanically ventilated patients may be at risk of experiencing elevated levels of mechanical power. Despite observed differences in mechanical power values between VC and PC ventilation, they did not result in a significant disparity in the prevalence of high mechanical power values.