Medicina Intensiva最新文献

Objective

To describe the high-flow nasal cannula (HFNC) indications in the Spanish pediatric critical care units (PICUs).

Design

Descriptive cross-sectional observational study.

Setting

Electronic survey among members of the Spanish Society of Pediatric Intensive Care (SECIP). It was sent weekly from April 10, 2023, to May 21, 2023.

Participants

All SECIP members.

Interventions

None.

Main variables of interest

The questions focused on workplace, years of experience, use or non-use of HFNC, justification and expectations regarding its application, starting point within each center, clinical criteria for indication, existence of clinical guidelines, evaluation during its use, and criteria and mode of withdrawal.

Results

Two hundred and two participants, 176 were from Spain. Of these, 87/176 had over ten years of experience. One hundred sixty two use HFNC and 66/162 have HFNC clinical guidelines. Acute bronchiolitis (138/162) and respiratory assistance after extubation (106/56) are the two main indications. For 62/162 HFNC may reduce therapeutic escalation. Neuromuscular diseases (105/162) and anatomical airway diseases (135/162) are the two main contraindications. The reasons to do not use HFNC were the absence of evidence about it effectiveness (8/14) and its inadequate cost/effectiveness balance (8/14).

Conclusions

A majority of Spanish pediatric intensivists use HFNC. Its application and withdrawal appears to be primarily based on clinical experience. Besides, those who use HFNC are aware of its limitations and the lack of evidence in some cases. It is necessary to develop single-center and multicenter studies to elucidate the effectiveness of this therapy in the context of critically ill children.

Objective

Compare prevalence and profile of post-intensive care patient (P-PICS) and family/caregiver (F-PICS) syndrome in two cohorts (COVID and non-COVID) and analyse risk factors for P-PICS.

Design

Prospective, observational cohort (March 2018- 2023), follow-up at three months and one year.

Setting

14-bed polyvalent Intensive Care Unit (ICU), Level II Hospital.

Patients or participants

265 patients and 209 relatives. Inclusion criteria patients: age > 18 years, mechanical ventilation > 48 hours, ICU stay > 5 days, delirium, septic shock, acute respiratory distress syndrome, cardiac arrest. Inclusion criteria family: those who attended.

Interventions

Follow-up 3 months and 1 year after hospital discharge.

Main variables of interest

Patients; sociodemographic, clinical, evolutive, physical, psychological and cognitive alterations, dependency degree and quality of life. Main caregivers: mental state and physical overload.

Results

64.9% PICS-P, no differences between groups. COVID patients more physical alterations than non-COVID (p = 0.028). These more functional deterioration (p = 0.005), poorer quality of life (p = 0.003), higher nutritional alterations (p = 0.004) and cognitive deterioration (p< 0.001). 19.1% PICS-F, more frequent in relatives of non-COVID patients (17.6% vs. 5.5%; p = 0.013). Independent predictors of PICS-P: first years of the study (OR: 0.484), higher comorbidity (OR: 1.158), delirium (OR: 2.935), several reasons for being included (OR: 3.171) and midazolam (OR: 4.265).

Conclusions

Prevalence PICS-P and PICS-F between both cohorts was similar. Main factors associated with the development of SPCI-P were: higher comorbidity, delirium, midazolam, inclusion for more than one reason and during the first years.

Objective

To investigate the association between the duration of the first prone positioning maneuver (PPM) and 90-day mortality in patients with C-ARDS.

Design

Retrospective, observational, and analytical study.

Setting

COVID-19 ICU of a tertiary hospital.

Patients

Adults over 18 years old, with a confirmed diagnosis of SARS-CoV-2 disease requiring PPM.

Interventions

Multivariable analysis of 90-day survival.

Main variables of interest

Duration of the first PPM, number of PPM sessions, 90-day mortality.

Results

271 patients undergoing PPM were analyzed: first tertile (n = 111), second tertile (n = 95) and third tertile (n = 65). The results indicated that the median duration of PDP was 14 hours (95% CI: 10-16 hours) in the first tertile, 19 hours (95% CI: 18-20 hours) in the second tertile and 22 hours (95% CI: 21-24 hours) in the third tertile. Comparison of survival curves using the Logrank test did not reach statistical significance (P = .11). Cox Regression analysis showed an association between the number of pronation sessions — patients receiving between 2 and 5 sessions (HR: 2.19; 95% CI: 1.07-4.49) and those receiving more than 5 sessions (HR: 6.05; 95% CI: 2.78-13.16 — and 90-day mortality.

Conclusions

While the duration of PDP does not appear to significantly influence 90-day mortality, the number of pronation sessions is identified as a significant factor associated with an increased risk of mortality.

Objective

To determine the relative effectiveness of Helmet-CPAP (H_CPAP) with respect to high-flow nasal cannula oxygen therapy (HFNO) in avoiding greater need for intubation or mortality in a medium complexity hospital in Chile during the year 2021.

Design

Cohort analytical study, single center.

Setting

Units other than intensive care units.

Patients

Records of adults with mild to moderate hypoxemia due to coronavirus type 2.

Interventions

None.

Main variables of interest

Need for intubation or mortality.

Results

159 patients were included in the study, with a ratio by support of 2:10 (H_CPAP:HFNO). The 46.5% were women, with no significant differences by sex according to support (p = 0.99, Fisher test). The APACHE II score, for HFNO, had a median of 10.5, 3.5 units higher than H_CPAP (p < 0.01, Wilcoxon rank sum). The risk of intubation in HFNO was 42.1% and in H_CPAP 3.8%, with a significant risk reduction of 91% (95% CI: 36.9%–98.7%; p < 0.01). APACHE II does not modify or confound the support and intubation relationship (p > 0.2, binomial regression); however, it does confound the support and mortality relationship (p = 0.82, RR homogeneity test). Despite a 79.1% reduction in mortality risk with H_CPAP, this reduction was not statistically significant (p = 0.11, binomial regression).

Conclusions

The use of Helmet CPAP, when compared to HFNO, was an effective therapeutic ventilatory support strategy to reduce the risk of intubation in patients with mild to moderate hypoxemia caused by coronavirus type 2 in inpatient units other than intensive care. The limitations associated with the difference in size, age and severity between the arms could generate bias.

The use of sedatives in intensive care units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.