Medicina intensiva最新文献

Objective: The purpose of this study was to analyze the differences in the effectiveness and complications of CPAP versus non-invasive ventilation on bilevel positive airway pressure (BiPAP) in the treatment of COVID-19 associated acute respiratory failure (ARF).

Design: Retrospective observational study.

Setting: ICU.

Patients: All COVID-19 patients, admitted to an ICU between March 2020 and February 2023, who required CPAP or BiPAP were analyzed.

Interventions: Use of CPAP or BiPAP in COVID-19 associated ARF.

Main variables of interest: Initial clinical variables, CPAP and BiPAP failure rate, complications, in-hospital mortality.

Results: 429 patients were analyzed, of whom 328 (76.5%) initially received CPAP and 101 (23.5%) BiPAP. Initial respiratory rate was 30 ± 8 in the CPAP group and 34 ± 9 in BiPAP (p < 0.001), while PaO₂/FiO₂ was 120 ± 26 and 111 ± 24 mmHg (p = 0.001), respectively. The most frequent complication related to the device was claustrophobia/discomfort, 23.2% in CPAP and 25.7% in BiPAP (p = 0.596), while the most frequent complications not related to the device were severe ARDS, 58.6% and 70.1% (p = 0.044), and hyperglycemia, 44.5% and 37.6%, respectively (p = 0.221). After adjusting by propensity score matched analysis, neither failure of the device (OR 1.37, CI 95% 0.72-2.62) nor in-hospital mortality (OR 1.57, CI 95% 0.73-3.42) differed between both groups.

Conclusions: Either non-invasive ventilatory device failure or mortality rate differed in patients initially treated with CPAP versus BiPAP.

Objective: To determine whether the Reverse Shock Index multiplied by the Glasgow Coma Scale (rSIG) is a predictor of in-hospital mortality in patients with traumatic brain injury (TBI).

Design: This is a systematic review and meta-analysis.

Setting: A comprehensive search was conducted in five databases for studies published up to May 22, 2024, using a PECO strategy. Eight studies were identified for quantitative analysis and included in our meta-analysis.

Participants: The participants of the included primary studies.

Interventions: Patients with a low rSIG as a predictor of in-hospital mortality in TBI.

Main variables of interest: rSIG, in-hospital mortality, TBI.

Results: Our meta-analysis evaluated a total of eight observational studies encompassing 430,000 patients with TBI, observing 6,417 deaths (15%). After performing a sensitivity analysis, we found that patients with TBI and a low value of the reverse shock index multiplied by the Glasgow Coma Scale (rSIG) had a 24% higher risk of death (OR 1.24; 95% CI 1.12-1.38; I²: 96%). Furthermore, rSIG values were significantly higher in survivors compared to those who died (MD 7.72; 95% CI 1.86-13.58; I²: 99%).

Objective: We aimed to determine predictors of non-invasive ventilation (NIV) failure and validate a nomogram to identify patients at risk of NIV failure.

Design: Observational, analytical study of a retrospective cohort from a single center, compared with an external cohort (March 2020 to August 2021).

Setting: Two intensive care units (ICUs).

Patients: Patients with pneumonia due to severe acute respiratory syndrome (SARS-CoV-2) and NIV > 24 h (154 and 229 in each cohort).

Interventions: The training cohort identified NIV failure predictors. A nomogram, created via logistic regression, underwent validation with the Hosmer-Lemeshow (HL), calibration curve and test and area under the curve (AUC). Its external validity was tested using AUC.

Main variables of interest: Demographics, comorbidities, severity scores, NIV settings, vital signs, blood gases, and oxygenation at the start and 24 h after NIV, NIV failure.

Results: NIV failure was 37.6% and 18% in the training and validation cohorts, respectively. Risk factors for NIV failure inluded age, obesity, sequential organ failure assessment (SOFA) score at admission, and heart rate (HR) and heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR) 24 h post-NIV. The model's HL test result was 0.861, with an AUC of 0.89 (confidence interval [CI] 0.839-0.942); validation AUC was 0.547 (CI 0.449-0.645).

Conclusions: A predictive model using age, obesity, SOFA score, HR, and HACOR at 24 h predicts NIV failure in our COVID-19 patients but may not apply to other ICUs.

Objective: To determine whether the ROX index and its variations can predict the risk of intubation in ICU patients receiving NIV ventilation using large public ICU databases.

Design: Retrospective observational cohort study.

Setting: Patient data was extracted from both the AmsterdamUMCdb and the MIMIC-IV ICU databases, which contained data related to 20,109 and 50,920 unique patients.

Patients: Non-invasively mechanically ventilated.

Interventions: Retrospective review of variables.

Main variables of interest: To assess the predictive values of models for each index, the ROX and its variations mROX, ROX-HR and mROX-HR were calculated based on mean values of SpO₂, respiratory rate, FiO₂ and PaO₂ from 2-h windows within the first 12 h of NIV.

Results: 3344 patients were eligible for analysis of which 1344 were intubated, died or returned to NIV within 24 h of ending NIV. NIV failure group had higher SOFA scores and higher CRP levels at admission. There was no difference in duration of NIV therapy or 28-day mortality, but patients who failed NIV had longer length of stay. The best performing index was ROX with an AUROC of 0.626 at 10-12 h. All other indices for all other time windows were less discriminating.

Conclusions: The performance of ROX index and its variations to predict NIV failure in ICU patients across large public ICU databases was moderate at best and cannot currently be recommended for clinical decision support.

Objective: To evaluate the intrarater and interrater reliability of the Clinical Frailty Scale-Spain (CFS-España) and FRAIL-España and the internal consistency of the FRAIL-España when implemented in critically ill patients by intensive care nurses and physicians.

Design: Descriptive, observational and metric study.

Setting: intensive care unit (ICU) of Spain.

Patients: Patients >18 years, with >48 UCI hours.

Intervention: None.

Main variables of interest: On admission, frailty with CFS-España and FRAIL-España (by 3 nurses and 2 intensive care physicians), sex, age, comorbidities and severity.

Results: 1045 assessments were performed in 206 patients. Not frail patients on admission: 53% according to the CFS-Spain and 34% according to the FRAIL-Spain. The intraclass correlation coefficient (ICC) shows almost perfect intrarater concordance (>0.80 for CFS-España and >0.90 for FRAIL-España). Agreement by frailty strata (non-fragile, pre-fragile and fragile patients) was substantial or almost perfect, with no major differences in ratings between nurses and physicians. Interprofessional concordance shows an almost perfect ICC for both scales. The lowest agreement was obtained for the FRAIL-España ratings among physicians. In the frailty strata analysis, agreement was moderate. The highest agreement for the CFS-España was considering level 4 patients as frail. High reliability of the FRAIL-España and strong correlation of all dimensions with the global assessment were obtained, except for the comorbidities dimension, with a weak correlation.

Conclusion: The CFS-España and FRAIL-España scales are reliable for assessing frailty in critically ill patients by nurses and/or intensive care physicians.

Objective: To document the experience with ECMO therapy in healthcare institutions across Latin America between 2016 and 2020.

Design: Cross-sectional study.

Setting: Private and public health institutions from 7 countries.

Participants: ECMO Intensive Care Units.

Interventions: None.

Main variables of interest: General characteristics of the center (country, ELSO center, year of first cannulation, public or private network, ECMO devices available, mobile ECMO), professional category (nurses, physicians, specialists and other professionals), nurse-to-patient ratio, interventions applied(support indications, scores, mechanical ventilation at ECMO commencement, anticoagulation and hemolysis, circuit monitoring and patient perfusion, antibiotic prophylaxis), and patient outcomes (complications and survival) in ECMO centers.

Results: Thirteen ECMO units were included. These units reported 133 consoles and 1629 ECMO cannulations. Of these, 1018 corresponded to adult patients, 468 to pediatric patients, and 143 to newborn infants. A total of 310 medical specialists were involved in ECMO care, of whom 70.3% had received ECMO training. The nurse-to-patient ratio was 1:1 in most centers (76.9%, n = 10). Amongst adult patients, the most common indication for initiating ECMO support was refractory hypoxemia, whereas in pediatric patients, it was a post-cardiotomy shock. The mean overall survival rate of the patients at the time of decannulation was 55.7% (95%CI 53.0-58.3).

Conclusions: The ICUs with ECMO in Latin America participating in this study have demonstrated operational capabilities enabling them to achieve outcomes comparable to those of other ECMO units across the world.

The host and microbes play complex roles in balancing the pro- and anti-inflammatory pathways that cause sepsis. It is now increasingly recognized as a disorder of the mitochondrial system intrinsically or as a consequence of microcirculatory abnormalities leading to hypoperfusion/hypoxia ("microcirculatory and mitochondrial distress syndrome"). It is expected that improvements in endothelium or mitochondrial level therapy will lower sepsis-related morbidity and mortality. This article aimed to clarify the mitochondrial and microcirculation abnormalities in patients with sepsis and the futuristic research agenda for the management of sepsis.

Objectives: The main objective of this study was to evaluate whether the implementation of CoBaTrICE (Competency-Based Training in Intensive Care Medicine in Europe) provides higher levels of competency in comparison with the current official time-based program in Intensive Care Medicine in Spain. Secondary objectives were: 1) To determine the percentage of critical essential performance elements (CEPE) accomplished, 2) To determine compliance with workplace-based assessments (wba).

Design: Multicenter cluster randomized trial.

Setting: Thirteen Spanish ICU Departments.

Participants: Thirty-six residents INTERVENTION: The implementation of CoBaTrICE included: (1) Training the trainers; (2) Wba; (3) The use of an electronic portfolio. The level of competency achieved by each participant was determined by a simulation-based Objective Structured Clinical Exam (OSCE) performed at the end of the 5th year of training period.

Main variables of interest: Total scoring in the five scenarios, CEPE completed, level of competency (1-5) achieved.

Results: A total of 119 performances from 26 residents (17 from CoBaTrICE group and 9 from control group) were analyzed in the OSCE. CoBaTrICE residents´ achieved higher levels of competency [2 (1-5) vs. 2 (1-3), p = 0.07) and higher percentages of CEPE´s accomplishment than the control group (78% vs. 71%, p = 0.09).

Conclusions: The CoBaTrICE group showed a better performance trend in comparison to the control group, but the differences were not statistically significant. Since the number of Wba performed was low, additional research is needed to determine the potential superiority of CoBaTrICE.