Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 µg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 µg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 µg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.

[Evaluation of pain during mobilization and endotracheal aspiration in critical patients]. / Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos.

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of ≥3 indicating pain. Various physiological signs and BIS values were recorded, with changes of >10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (-2 [IQR: {-5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures.

[Pressure support ventilation and proportional assist ventilation during weaning from mechanical ventilation]. / Ventilación con presión de soporte y ventilación proporcional asistida durante la retirada de la ventilación mecánica.

OBJECTIVES: To compare tolerance, duration of mechanical ventilation (MV) and clinical outcomes during weaning from MV in patients subjected to either pressure support ventilation (PSV) or proportional assist ventilation (PAV). DESIGN: A prospective, observational study was carried out. SETTING: Intensive Care Unit. PATIENTS: A total of 40 consecutive subjects were allocated to either the PSV or the PAV group until each group contained 20 patients. Patients were included in the study when they met the criteria to begin weaning and the attending physician decided to initiate the weaning process. The physician selected the modality and set the ventilatory parameters. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic data, respiratory mechanics, ventilatory parameters, duration of MV, and clinical outcomes (reintubation, tracheostomy, mortality). RESULTS: Baseline characteristics were similar in both groups. No significant differences were observed between the PSV and PAV groups in terms of the total duration of MV (10 [5-18] vs. 9 [7-19] days; P=.85), reintubation (5 [31%] vs. 3 [19%]; P=.69), or mortality (4 [20%] vs. 5 [25%] deaths; P=1). Eight patients (40%) in the PSV group and 6 patients (30%) in the PAV group (P=.74) required a return to volume assist-control ventilation due to clinical deterioration. CONCLUSIONS: Tolerance, duration of MV and clinical outcomes during weaning from mechanical ventilation were similar in PSV and PAV.

Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study.

AIMS: To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). DESIGN: Prospective, multicentre cohort study. SCOPE: Thirty-two Spanish ICUs. PATIENTS: Adult patients admitted to the ICU between April and June 2017. INTERVENTION: Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). MAIN VARIABLES OF INTEREST: Incidence of AHF and 30-day mortality. RESULTS: A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04). CONCLUSIONS: The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF.

Glucocorticoids in the treatment of acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is characterized by local inflammation and an intense systemic inflammatory reaction. Glucocorticoid administration has been suggested due to their anti-inflammatory properties. However, results from the initial studies of glucocorticoids in ARDS, which evaluated high-dose and short-term treatments, were negative. More recent studies have evaluated the effect of lower doses of glucocorticoids administered over longer periods, but the results thus far have been inconclusive.

Le syndrome de détresse respiratoire aiguë (SDRA) est caractérisé par une inflammation locale et une réaction inflammatoire systémique intense. L'administration de glucocorticoïdes a été proposée en raison de leurs propriétés anti-inflammatoires. Cependant, les résultats des premières études concernant la prescription des glucocorticoïdes dans le SDRA, qui ont évalué de hautes doses avec des traitements de court terme, ont été négatifs. Des études plus récentes ont évalué des doses plus basses administrées sur des périodes plus longues, mais les résultats ont aussi été peu concluants.

Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study.

BACKGROUND: No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. PATIENTS AND METHODS: This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). RESULTS: Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5-47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14-65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. CONCLUSION: Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos / Evaluation of pain during mobilization and endotracheal aspiration in critical patients

OBJETIVOS: 1) Evaluar la prevalencia de dolor durante 2 procedimientos de enfermería, y 2) analizar la utilidad de ciertos signos vitales y del índice biespectral (BIS) para detectar dolor. MÉTODOS: Estudio prospectivo, observacional y analítico de medidas repetidas en pacientes con ventilación mecánica y sedación. Los procedimientos evaluados fueron la aspiración endotraqueal y la movilización con giro. El dolor se evaluó mediante la Behavioral Pain Scale. Valores más o igual se consideraron dolorosos. Se registraron distintos signos fisiológicos y los valores del BIS. Una variación porcentual > 10% se consideró clínicamente relevante. RESULTADOS: Se analizaron 146 procedimientos en 70 pacientes. La prevalencia de dolor durante los procedimientos fue del 94%. Los signos vitales y los valores del BIS aumentaron significativamente durante los procedimientos respecto el reposo, pero solo la variación del BIS alcanzó relevancia clínica. En un subgrupo de pacientes que recibieron analgesia preventiva antes de los procedimientos, el dolor disminuyó significativamente respecto a los pacientes que no recibieron analgesia preventiva (−2 [RIQ: {−5}-0] vs. 3 [RIQ: 1-4]; p<0,001, respectivamente). CONCLUSIONES: Los procedimientos evaluados son dolorosos. La variación de los signos vitales no es un buen indicador de dolor. La variación del BIS podría ser útil, pero precisa nuevas investigaciones. La administración de analgesia preventiva disminuye la prevalencia de dolor durante los procedimientos

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of more or equal 3 indicating pain. Various physiological signs and BIS values were recorded, with changes of > 10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (−2 [IQR: {−5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures

Can procalcitonin help identify associated bacterial infection in patients with severe influenza pneumonia? A multicentre study.

PURPOSE: To determine whether procalcitonin (PCT) levels could help discriminate isolated viral from mixed (bacterial and viral) pneumonia in patients admitted to the intensive care unit (ICU) during the A/H1N1v2009 influenza pandemic. METHODS: A retrospective observational study was performed in 23 French ICUs during the 2009 H1N1 pandemic. Levels of PCT at admission were compared between patients with confirmed influenzae A pneumonia associated or not associated with a bacterial co-infection. RESULTS: Of 103 patients with confirmed A/H1N1 infection and not having received prior antibiotics, 48 (46.6%; 95% CI 37-56%) had a documented bacterial co-infection, mostly caused by Streptococcus pneumoniae (54%) or Staphylococcus aureus (31%). Fifty-two patients had PCT measured on admission, including 19 (37%) having bacterial co-infection. Median (range 25-75%) values of PCT were significantly higher in patients with bacterial co-infection: 29.5 (3.9-45.3) versus 0.5 (0.12-2) µg/l (P < 0.01). For a cut-off of 0.8 µg/l or more, the sensitivity and specificity of PCT for distinguishing isolated viral from mixed pneumonia were 91 and 68%, respectively. Alveolar condensation combined with a PCT level of 0.8 µg/l or more was strongly associated with bacterial co-infection (OR 12.9, 95% CI 3.2-51.5; P < 0.001). CONCLUSIONS: PCT may help discriminate viral from mixed pneumonia during the influenza season. Levels of PCT less than 0.8 µg/l combined with clinical judgment suggest that bacterial infection is unlikely.

Ventilación con presión de soporte y ventilación proporcional asistida durante la retirada de la ventilación mecánica / Pressure support ventilation and proportional assist ventilation during weaning from mechanical ventilation

OBJETIVOS: Comparar la tolerancia, la duración de la ventilación mecánica (VM) y los desenlaces clínicos durante la retirada de la VM en 2 modalidades ventilatorias: la ventilación con presión de soporte (PSV) frente a la ventilación proporcional asistida (VPA). DISEÑO: Estudio observacional y prospectivo. Ámbito: Servicio de Medicina Intensiva. PACIENTES: Inclusión consecutiva de 20 pacientes en PSV y 20 pacientes en VPA cuando cumplieron los criterios de inicio de retirada de VM y su médico responsable decidió iniciar este proceso. La modalidad ventilatoria escogida y los parámetros ventilatorios durante el estudio fueron realizados por su médico responsable. INTERVENCIONES: Ninguna. Variables de interés: Variables demográficas, de mecánica respiratoria, parámetros ventilatorios, duración de VM y desenlaces clínicos (reintubación, traqueostomía, mortalidad).RESULTADOS: Los 2 grupos fueron similares en sus características basales. No existieron diferenciasen la duración total de VM (10 [5-18] días en PSV frente a 9 [7-19] días en VPA; p = 0,85).Tampoco existieron diferencias en términos de reintubación (5 [31%] en PSV frente a 3 [19%] enVPA; p = 0,69) ni de mortalidad (4 [20%] en PSV frente a 5 [25%] en VPA; p = 1). Ocho pacientes (40%) en PSV y 6 en VPA (30%) (p = 0,74) presentaron deterioro clínico y requirieron regresar a la modalidad asistida controlada por volumen. CONCLUSIONES: La PSV y la VPA presentan similar tolerancia, duración de la VM y desenlaces clínicos durante la retirada de esta

OBJECTIVES: To compare tolerance, duration of mechanical ventilation (MV) and clinical outcomes during weaning from MV in patients subjected to either pressure support ventilation (PSV)or proportional assist ventilation (PAV).DESIGN: A prospective, observational study was carried out. SETTING: Intensive Care Unit. PATIENTS: A total of 40 consecutive subjects were allocated to either the PSV or the PAV groupuntil each group contained 20 patients. Patients were included in the study when they met the criteria to begin weaning and the attending physician decided to initiate the weaning process. The physician selected the modality and set the ventilatory parameters. INTERVENTIONS: None. Variables of interest: Demographic data, respiratory mechanics, ventilatory parameters, duration of MV, and clinical outcomes (reintubation, tracheostomy, mortality).RESULTS: Baseline characteristics were similar in both groups. No significant differences were RESULTS: Baseline characteristics were similar in both groups. No significant differences were observed between the PSV and PAV groups in terms of the total duration of MV (10 [5-18] vs. 9 [7-19] days; P = .85), reintubation (5 [31%] vs. 3 [19%]; P = .69), or mortality (4 [20%] vs. 5 [25%] deaths; P = 1). Eight patients (40%) in the PSV group and 6 patients (30%) in the PAV group (P = .74) required a return to volume assist-control ventilation due to clinical deterioration. CONCLUSIONS: Tolerance, duration of MV and clinical outcomes during weaning from mechanical ventilation were similar in PSV and PAV

Embolismo gaseoso cerebral por accidente de buceo / Cerebral gas embolism as a result of diving accident

La patología relacionada con los accidentes de buceo es quizás poco conocida por su baja prevalencia. Se clasifica en no disbárica o disbárica, en función de su relación con cambios de presión. Presentamos el caso de un buceador que, después de realizar una inmersión de 30 minutos a 22 metros de profundidad, presentó bradipsiquia y afasia transitoria. En la tomografía axial computarizada craneal se objetivó un infarto silviano izquierdo. Se realizó tratamiento en cámara hiperbárica con buena evolución clínica. En relación con el caso, revisamos las distintas formas de presentación de los accidentes disbáricos, así como la utilidad de la cámara hiperbárica en el tratamiento

Clinical alterations related to diving accidents are little known perhaps because of its low prevalence. They can be classified as dysbarism-related and non-dysbarism-related according to its relation with pressure changes. We present the case of a diver that showed bradypsychia and transitory aphasia after carrying out an immersion of 30 minutes in duration and 22 meters deep. A left sylvian cerebral infarct was demostrated in cranial computerized axial tomography. Treatment was carried out in a hyperbaric chamber with good clinical evolution. We review with regard to this case the different forms of clinical presentation of dysbarism-related accidents, as well as the usefulness of the hyperbaric chamber in their treatment