Follow-up program after intensive care unit discharge. / Programa de seguimiento al alta de la unidad de cuidados intensivos.

INTRODUCTION: Patient follow-up after intensive care unit (ICU) discharge allows the early recognition of complications associated to post-intensive care syndrome (PICS). The aim of this project is to standardize outcome variables in a follow-up program for patients at risk of suffering PICS. METHODS: The Rehabilitation and Patient Follow-up Committee of the Argentine Society of Intensive Care Medicine (Sociedad Argentina de Terapia Intensiva, SATI) requested the collaboration of different committees to design the present document. A thorough search of the literature on the issue, together with pre-scheduled meetings and web-based discussion encounters were carried out. After comprehensive evaluation, the recommendations according to the GRADE system included in the follow-up program were: frequency of controlled visits, appointed healthcare professionals, basic domains of assessment and recommended tools of evaluation, validated in Spanish, and entire duration of the program. CONCLUSION: The measures herein suggested for patient follow-up after ICU discharge will facilitate a basic approach to diagnosis and management of the long-term complications associated to PICS.

A systematic review and individual patient data meta-analysis on intra-abdominal hypertension in critically ill patients: the wake-up project. World initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!).

Intra-abdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. The aim of this paper was to evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intra-abdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (N.=712), absence of information on ICU outcome (N.=195), age <18 or >95 years (N.=131). Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

A Systematic Review And Individual Patient Data Meta-Analysis On Intraabdominal Hypertension In Critically Ill Patients: The Wake-Up Project World Initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!).

Background: Intraabdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. Objective: To evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. Data sources: An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intraabdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (n=712), absence of information on ICU outcome (n=195), age <18 or > 95 years (n=131). Results: Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. Conclusions: This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

OS024. Characteristics and outcomes of critically ill obstetric patientswith hypertensive disease of pregnancy in argentina: Multicenter study.

INTRODUCTION: Worldwide, hypertensive disease of pregnancy is one of the most frequent causes of admission of obstetric patients to the ICU. Maternal mortality risk related to Hypertension during pregnancy in Latin America is significantly higher than in developed countries. OBJECTIVES: To describe the characteristics and outcomes of pregnant-postpartum patients with hypertensive disease of pregnancy admitted to ICU METHODS: DESIGN: Multicenter case series study. POPULATION: pregnant-postpartum (<42days) patients with hypertensive disease of pregnancy admitted to ICU. SETTING: 3 ICUs in Argentina, 2 from the Public (P1) and 1 from the Private Health Sector (P2). STATISTICS: Continuous data are presented as mean±SD or median [IQR], and categorical data as number (%). Comparisons among continuous data were performed with unpaired t test or Mann-Whitney U test. Categorical variables were analyzed by Chi-square test or Fisher exact test as appropriate. A two-sided α<0.05 was considered as significant. SPSS version 15 was used. RESULTS: One hundred and eighty four patients were included, 161(87.5%) from P1. General characteristics are shown in the Table. Gestational age was 34±5 weeks. Risk factors for preeclampsia not included in Charlson score were chronic hypertension (22;12%), Obesity (6;3%) and preeclampsia in previous pregnancy (5;3%). ICU admission was postpartum in 80%(145). Causes of admission were eclampsia (63;34%), severe preeclampsia (61;33%), HELLP (33;18%), Eclampsia-HELLP (18;10%), Chronic Hypertension (5;3%) and Gestational Hypertension (4;2%). Predictive mortality according with APACHEII was 14%. Antenatal care was present in 115/142(81%) patients; 97/124(78%) in P1 vs 18/18 (100%) in P2; p0.024. Antenatal care was appropriate in 77/108(71.3%) of patients; 59/90(65.5%) in P1 vs 18/18(100%) in P2; p0.001. Maternal deaths (6) occurred in the Public sector and none of the patients had received antenatal care. Causes of mortality were hemorrhagic stroke (3) and multiple organ dysfunction (3) Table 1. CONCLUSION: Most patients were from the public health sector and the majority did not have any comorbidity according with the Charlson score. Nevertheless, 18% presented risk factors for preeclampsia, not included in the mentioned score. Two-thirds of patients were admitted with eclampsia and severe preeclampsia. APACHEII overpredicted mortality. Half of deaths were related with hemorrhagic stroke, complication almost eradicated from developed countries. None of the patients who died had received antenatal care.

Infección del sitio de salida de los catéteres venosos centrales y su asociación con bacteriemia relacionada con catéter / Infection of the exit site central venous catheters and its association with bacteremia related to catheter

Introducción: Los catéteres venosos centrales (CVC) plantean un alto riesgo de infección. La infección del sitio de salida (ISS-CVC) es la menos estudiada, y se desconoce su asociación con la bacteriemia asociada a catéter (BAC) y su impacto en la evolución del paciente. Objetivo: Evaluar la asociación entre ISS-CVC, BAC y mortalidad. Materiales y métodos: Estudio prospectivo, de observación. Pacientes internados en una Unidad de Terapia Intensiva médico/quirúrgica que requirieron la colocación de CVC desde el 01/06/2010 hasta el 01/04/2012. Se evaluaron datos epidemiológicos, BAC (según criterios de los CDC) y gérmenes. Se utilizaron media ± DE, mediana y rango intercuartílico, y porcentajes. Resultados: Durante este período, ingresaron 575 pacientes, el 98% requirió CVC. Datos de los pacientes: edad 41 ± 26 años, APACHE II 15 ± 7, 96% con ventilación mecánica, días de ventilación mecánica 41 (33-63), días de internación 43 (25-67). Todos los CVC con ISS fueron retirados y cultivados. Se observaron 51 ISS: 5,5/1000-días-catéter: 33% subclavia, 38% yugular, 29% femoral. Seis pacientes con ISS (12%) tuvieron BAC (0,65/1000-días-catéter): 3 subclavias, 2 yugulares, 1 femoral; 2 con halo y 8 con secreción purulenta. Tiempo de permanencia del CVC: 7,5 días (5-10). Clínica al momento de la ISS: shock 50%, fiebre 83%, SOFA 6 ± 3. El 83% de las infecciones fueron monomicrobianas: 83% por bacilos gramnegativos (2 Klebsiella, 2 Pseudomonas, 1 Serratia y 1 Acinetobacter), 17% por enterococos resistentes a vancomicina. La mortalidad fue del 50%. Conclusión: Aunque la ISS provocó una baja incidencia de BAC, la mortalidad fue alta. Al parecer, la ISS no es un factor predictivo de BAC.(AU)

Introduction: Central venous catheters (CVC) are widely used and pose a high risk of infection. There are few studies on insertion site infection (ISI-CVC), and both its association with catheter-associated bloodstream infection (CABSI) and the outcome of patients are unknown. Objective: To determine the association between ISI-CVC, the presence of CABSI and mortality. Materials and methods: Prospective observational study. All patients admitted to a medical/surgical Intensive Care Unit requiring CVC insertion from 06/01/2010 to 04/01/2012 were included. Epidemiological data, CABSI (according to CDC criteria) and microorganisms involved were evaluated. Mean ± SD, median and interquartile range, and percentages were used. Results: During the period study, 575 patients were admitted, 98% required CVC. Patient´s data: age 41 ± 26 years, APACHE II 15 ± 7, 96% on mechanical ventilation, days on mechanical ventilation: 41 (33-63), length of stay 43 (25-67) days. All CVCs with ISI were removed and cultured. Fifty one ISI were observed (5.5/1000-catheter-day). Six patients with ISI (12%) presented CABSI (0.65/1000-catheter-day): 3 in subclavian, 2 in jugular, 1 femoral; 2 with erythema and 8 with purulent secretion. CVC permanence: 7.5 day (5-10). Signs and/or symptoms at the moment of ISI: shock 50%, fever 83%, SOFA 6 ± 3. The 83% of infections were caused by one microorganism: 83% due to gram-negative bacilli (2 Klebsiella, 2 Pseudomonas, 1 Serratia, and 1 Acinetobacter), 17% due to vancomycin-resistant enterococci. The mortality rate was 50%. Conclusion: Although ISI-CVC presented a low incidence of CABSI, mortality rate was high. The ISI-CVC might have a little predictable value for CABSI.(AU)

Impacto de la crisis económica argentina sobre la incidencia de infecciones y la evolución en la Unidad de Cuidados Intensivos / Impact of the economic crisis Argentina on the incidence of infections and the evolution in Intensive care unit

Introducción. La crisis económica argentina disminuyó la provisión adecuada de insumos en los hospitales públicos. Objetivos. 1) Evaluar si la reducción de insumos impactó en la evolución de los pacientes; 2) cuantificar la provisión de insumos durante los períodos precrisis (P1), crisis y poscrisis (P2); 3) evaluar la incidencia de infecciones durante los tres períodos. Materiales y métodos. Se evaluó la densidad de incidencia de las infecciones intrahospitalarias, la estadía en la Unidad de Terapia Intensiva y la mortalidad en los tres períodos. Los datos se presentan como media ± desviación estándar, mediana [IC 0,25-0,75] y porcentajes de acuerdo con su naturaleza. Las comparaciones se efectuaron con la prueba t o ji cuadrado. Se consideró significativo un valor p <0,05. Resultados. Durante la crisis, ingresaron pacientes con menos enfermedades preexistentes, permanecieron más días ventilados y aumentó significativamente el número de infecciones por paciente. En el período P2, se detectó una caída significativa del número de pacientes infectados con respecto a los dos períodos anteriores. En el período P1, no hubo diferencias entre la mortalidad de los infectados y de los no infectados (25% contra 33%, p = 0,31). Durante la crisis, la mortalidad de los no infectados fue menor (19% contra 40%, p = 0,0005). La provisión de insumos disminuyó durante la crisis. Las infecciones intrahospitalarias se incrementaron en forma absoluta y como densidad de incidencia durante la crisis, y descendieron en el período P2. Conclusión. Durante la crisis económica, se recortaron los gastos de insumos y aumentó el número de infecciones por paciente.(AU)

Introduction. The collapse of the Argentinean economy in 2001 caused a shortage of material resources in public hospitals. Objectives. 1) To evaluate whether the decrease of material resources affected the outcome of patients in the Intensive Care Unit; 2) to quantify the provision of resources received in the Intensive Care Unit during three periods: Pre-crisis (P1), crisis, and post-crisis (P2); 3) to evaluate the incidence of infections during the three periods. Materials and methods. We compared the incidence of nosocomial infec- incidence of nosocomial infections; Intensive Care Unit stay, and mortality in the three periods. Data are presented as media ± SD, median [IQ 0.25-0.75], and percentages according to their nature. Comparison were performed using t test and chi-squared test. A p value <.05 was considered significant. Results. During the crisis, patients with less co-morbidities were admitted, they spent more time on mechanical ventilation, and the number of infections per patient was higher. Instead, during P2, there was a significant reduction of patients infected in relation to P1 and the crisis period. In P1, mortality did not differ between infected versus non-infected patients (25% vs. 33%; p = 0.31). However, during the crisis, mortality in non-infected patients was lower (19% vs. 40%; p = 0.0005). In the crisis, provision of materials decreased. Nosocomial infections increased. The incidence of infections decreased during P2. Conclusion. Resource availability decreased significantly during the economic crisis with a marked increase in the incidence of infections in the Intensive Care Unit. (AU)

Evaluación del Sequential Organ Failure Assessmente (SOFA) score para predecir mortalidad en los pacientes críticos, y comparación con los scores APACHE II Y SAPS II / Sequential Organ Failure Assessment Assessed (SOFA) score to predict mortality in critically ill patients, and comparison with APACHE II scores and SAPS II

Objetivos: 1) Determinar la utilidad del SOFA score y sus variables derivadas como predictores de mortalidad 2) correlacionar la mortalidad estmada por el SOFA score y derivadas, con la predicha por APACHE II y SAPS II. Materiales y métodos: Diseño: cohorte prospectiva. Lugar UTI polivalente de un hospital escuela. Pacientes: los ingresados desde el 1/5/01 al 14/4/03. Al ingreso se calcularon los scores pronósticos APACHE II y SAPS II y SOFA inicial, y diariamente (hasta 30 días de internación), el score SOFA con los peores valores del día anterior. Adicionalmente se calcularon las siguintes variables derivadas: SOFA medio: valor promedio de la internación; SOFA total: suma de todos los valores diarios; delta SOFA 48hs: diferencia entre el SOFA inicial y a las 48 hs del ingreso; y SOFA máximo: el valor más alto registrado. Análisis estadístico: primeramente, se calculó el área bajo la curva ROCd (AUC) correspondiente a las 5 variables citadas, a APACHE IIy a SAPS II, y luego se compararon con refencia a la que presentó mayor AUC en el procedimeinto anterior...

Effects of hemorrhage on gastrointestinal oxygenation.

OBJECTIVES: (1) To demonstrate that metabolic parameters are better indicators of tissue hypoxia than regional and whole oxygen consumption (VO(2)). (2) To compare intramucosal pH (pHi) in different gastrointestinal segments. DESIGN: Prospective, interventional study. SETTING: Research laboratory at a university center. SUBJECTS: Fourteen anesthetized, mechanically ventilated dogs. INTERVENTIONS: Twenty milliliters per kilogram bleeding. MEASUREMENTS AND MAIN RESULTS: We placed pulmonary, aortic and mesenteric venous catheters, and an electromagnetic flow probe in the superior mesenteric artery, and gastric, jejunal and ileal tonometers to measure flows, arterial and venous blood gases and lactate, and intramucosal PCO(2). We calculated systemic and intestinal oxygen transport (DO(2)) and consumption (VO(2)), pHi and arterial minus intramucosal PCO(2) (DeltaPCO(2)). Then, we bled the dogs and repeated the measurements after 30 min. Systemic and intestinal DO(2) fell (26.0+/-7.3 versus 8.9+/-2.6 and 71.9+/-17.3 versus 24.6+/-9.6 ml/min per kg, respectively, p<0.0001). Systemic and intestinal VO(2) remained unchanged (5.5+/-1.3 versus 5.4+/-1.3 and 15.7+/-5.0 versus 14.9+/-5.3 ml/min per kg, respectively). Gastric, jejunal and ileal pHi (7.13+/-0.11 versus 6.96+/-0.17, 7.18+/-0.06 versus 6.97+/-0.15, 7.12+/-0.11 versus 6.94+/-0.14, p<0.05) and DeltaPCO(2) (21+/-13 versus 35+/-23, 15+/-5 versus 33+/-16, 23+/-17 versus 38+/-20, p<0.05) changed accordingly. Arterial and mesenteric venous lactate and their difference, rose significantly (1.7+/-0.9 versus 3.7+/-1.4 and 1.8+/-0.8 versus 4.3+/-1.5 mmol/l, 0.1+/-0.6 versus 0.6+/-0.7 mmol/l, p<0.05). CONCLUSIONS: During hemorrhage, systemic and intestinal VO(2) remained stable. However, hyperlactatemia and intramucosal acidosis evidenced anaerobic metabolism. pHi changes paralleled in the three intestinal segments.

Lack of agreement between tonometric and gastric juice partial carbon dioxide tension.

STATEMENT OF FINDINGS: Our goal was to compare measurement of tonometered saline and gastric juice partial carbon dioxide tension (PCO2). In this prospective observational study, 112 pairs of measurements were simultaneously obtained under various hemodynamic conditions, in 15 critical care patients. Linear regression analysis showed a significant correlation between the two methods of measuring PCO2 (r(2) = 0.43; P < 0.0001). However, gastric juice PCO2 was systematically higher (mean difference 51 mmHg). The 95% limits of agreement were 315 mmHg and the dispersion increased as the values of PCO2 increased. Tonometric and gastric juice PCO2 cannot be used interchangeably. Gastric juice PCO2 measurement should be interpreted with caution.

End-tidal CO2 pressure determinants during hemorrhagic shock.

OBJECTIVES: To examine the relationship between end-tidal CO2 (PETCO2) and its physiological determinants, pulmonary blood flow (cardiac output, CO) and CO2 production (VCO2), in a model of hemorrhagic shock during fixed minute ventilation. DESIGN AND SETTING: Prospective, observational study in a research laboratory at a university center. SUBJECTS AND INTERVENTIONS: Six anesthetized, intubated, and mechanically ventilated mongrel dogs. Progressive stepwise bleeding. MEASUREMENTS AND RESULTS: We continuously measured PETCO2 with a capnograph, pulmonary artery blood flow with an electromagnetic flow probe, arterial oxygen saturation (SaO2) with a fiberoptic catheter, and oxygen consumption (VO2) and VCO2 by expired gases analysis. Oxygen delivery (DO2) was continuously calculated from pulmonary blood flow and SaO2. We studied the correlation of PETCO2 with CO and VCO2 in each individual experiment. We also calculated the critical point in the relationships PETCO2/ DO2 and VO2/DO2 by the polynomial method. As expected, PETCO2 was correlated with CO. The best fit was logarithmic in all experiments (median r2 = 0.90), showing that PETCO2 decrease is greater in lowest flow states. PETCO2 was correlated with VCO2, but the best fit was linear (median r2 = 0.77). Critical DO2 for PETCO2 and VO2 was 8.0 +/- 3.3 and 6.3 +/- 2.5 ml x min(-1) kg(-1), respectively (NS). CONCLUSIONS: Our data reconfirm the relationship between PETCO2 and CO during hemorrhagic shock. The relatively greater decrease in PETCO2 at lowest CO levels could represent diminished CO2 production during the period of VO2 supply dependency.

Distintos comportamientos de la oxigenación sistémica e intestinal en el síndrome de distress respiratorio del adulto (ARDS) tratado con presión espiratoria positiva final (PEEP) / Different behaviors of the systemic and intestinal oxygenation in the adult respiratory distress syndrome treated with positive end-expiratory pressure

La relación entre disponibilidad y consumo de O2 (DO2 y VO2, respectivamente) ha sido extensamente estudiada en pacientes críticos. Sin embargo, existen pocos intentos de vincular éstas mediciones a la oxigenación tisular. Nosotros realizamos éste estudio en pacientes con ARDS tratados con PEEP con el propósito de demostrar que el pH intramucoso gástrico (pHi) podría contribuir al monitoreo de la oxigenación tisular y aportar información adicional sobre el significado de la relación VO2/DO2. Con éste objetivo, 11 pacientes con ARDS, sedados con diazepam, relajados con pancuronio y ventilados mecánicamente con una FiO2 de 1, fueron sometidos a incrementos secuenciales de PEEP a O, 10 y 15 cmH2O, con intervalos de 209 minutos. En cada caso se midieron pHi por tonometría, volumen minuto cardíaco por termodilución y contenidos arteriales y venosos mixtos de O2 (gases, Hb y saturación), calculándose DO2 y VO2. Se realizaron correlaciones entre DO2 y VO2 y DO2 y pHi por cuadrados mínimos. A través de un método de agrupamiento se distinguieron diferentes comportamientos. Adicionalmente, se incluyeron otros 2 pacientes para corroborar la metodología estadística. De ésta forma quedaron definidos 3 grupos. En el grupo I (6 pacientes), con las dismuinuciones de la DO2, el VO2 fue constante (r media 0,49 ñ 0,34), aunque el pHi se redujo (r media 0,90 ñ 0,09)...

Preservación de la oxigenación intestinal en la injuria pulmonar por ácido oleico (AO) / Preservation of the intestinal oxygenation in the lung injury by oleic acid

El síndrome séptico (SS) y el fallo multiorgánico (MOF) se desarrollan frecuentemente en el síndrome de distress respiratorio del adulto (ARDS), incluso cuando el transporte de 02 se mantiene dentro de límites normales. Una explicación para este fenómeno sería el desarrollo de la hipoxia intestinal y la eventual translocación bacteriana, ya que este territorio se considera particularmente susceptible a cambios en la disponibilidad de 02. Nosotros realizamos este estudio, en un modelo experimental canino de ARDS, con el objetivo de descartar la presencia de hipoxia intestinal oculta. Para esto, estudiamos siete perros, anestesiados y ventilados mecánicamente con una Fi02 de 0,50, a los que se les colocaron catéteres en las arterias pulmonar y femolar, para medición de volumen minuto cardíaco (Q) y obtención de muestras sanguíneas. A través de una laparatomía, se colocaron un transductor para medición electromagnética del flujo sanguíneo en la arteria mesentérica superior (Qi), un catéter en la vena mesentérica para extracción de muestras sanguíneas y un tonómetro para medición del pH intramucoso en un asa yeyunal (pHi). Se midieron pH, PC02, P02, Hb y saturación de 02 en las muestras sanguíneas. Se calcularon disponibilidades y consumos de 02 sistémicos e intestinales (D02, V02, D02i y V02i, respectivamente). Luego de las mediciones basales, se inyectaron 0,1 ml/kg de AO. Las mediciones se repitieron a los 30, 60, 90 y 120 minutos. A lo largo del experimento, se evitaron reducciones del Q por la infusión de solución fisiológica. La Pa02 (mediañSE) se redujo significativamente (248ñ11 versus 95ñ5,p<0,01). Sin embargo, D02i, V02i y pHi no sufrieron cambios significativos durante el desarrollo del edema pulmonar. Estos resultados podrían deberse a : 1) la capacidad intestinal de mantener su oxigenación, 2) la injuria no fue de suficiente magnitud y/o duración