[Interpretation of ventilator curves in patients with acute respiratory failure]. / Interpretación de las curvas del respirador en pacientes con insuficiencia respiratoria aguda.

Mechanical ventilation is a therapeutic intervention involving the temporary replacement of ventilatory function with the purpose of improving symptoms in patients with acute respiratory failure. Technological advances have facilitated the development of sophisticated ventilators for viewing and recording the respiratory waveforms, which are a valuable source of information for the clinician. The correct interpretation of these curves is crucial for the correct diagnosis and early detection of anomalies, and for understanding physiological aspects related to mechanical ventilation and patient-ventilator interaction. The present study offers a guide for the interpretation of the airway pressure and flow and volume curves of the ventilator, through the analysis of different clinical scenarios.

Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs late onset.

OBJECTIVE: To determine the impact of ventilator-associated pneumonia (VAP) on ICU mortality, and whether it is related to time of onset of pneumonia. DESIGN: Prospective cohort study. SETTING: 16-bed medical-surgical ICU at a university-affiliated hospital. PATIENTS AND MEASUREMENTS: From 2002 to 2003, we recorded patients receiving mechanical ventilation for > 72 h. Patients developing an infection other than VAP were excluded. Patients definitively diagnosed with VAP (n=40) were cases and patients free of any infection acquired during ICU stay (n=61) were controls. The VAP-attributed mortality was defined as the difference between observed mortality and predicted mortality (SAPS II) on admission. RESULTS: Mechanical ventilation was longer in VAP patients (25 +/- 20 vs 11 +/- 9 days; p < 0.001), as was ICU stay (33 +/- 23 vs 14 +/- 12 days; p < 0.001). In the non-VAP group, no difference was found between observed and predicted mortality (27.9 vs 27.4%; p > 0.2). In the VAP group, observed mortality was 45% and predicted mortality 26.5% (p < 0.001), with attributable mortality 18.5%, and relative risk (RR) 1.7 (95% CI 1.12-23.17). No difference was observed between observed and predicted mortality in early-onset VAP (27.3 vs 25.8%; p > 0.20); in late-onset VAP, observed mortality was higher (51.7 vs 26.7%; p < 0.01) with attributable mortality of 25% and an RR 1.9 (95% CI 1.26-2.63). Empiric antibiotic treatment was appropriate in 77.5% of episodes. No differences in mortality were related to treatment appropriateness. CONCLUSIONS: In mechanically ventilated patients, VAP is associated with excess mortality, mostly restricted to late-onset VAP and despite appropriate antibiotic treatment.

[Telemedicine: Improving the quality of care for critical patients from the pre-hospital phase to the intensive care unit]. / Telemedicina: mejora de la calidad en la atención de los pacientes críticos desde la fase prehospitalaria hasta el servicio de medicina intensiva.

The Health System is in crisis and critical care (from transport systems to the ICU) cannot escape from that. Lack of integration between ambulances and reference Hospitals, a deep shortage of critical care specialists and assigned economical resources that increase less than critical care demand are the cornerstones of the problem. Moreover, the analysis of the situation anticipated that the problem will be worse in the future. "Closed" ICUs in which critical care specialists direct patient care outperform "open" ones in which primary admitting physicians direct patient care in consultation with critical care specialists. However, the current paradigm in which a critical care specialist is close to the patient is in the edge of the trouble so, only a new paradigm could help to increase the number of patients under intensivist care. Current information technology and networking capabilities should be fully exploited to improve both the extent and quality of intensivist coverage. Far to be a replacement of the existing model Telemedicine might be a complimentary tool. In fact, to centralize medical data into servers has many additional advantages that could even improve the way in which critical care physicians take care of their patients under the traditional system.