Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial.

OBJECTIVE: We examined the effect on survival of prone positioning as an early and continuous treatment in ARDS patients already treated with protective ventilation. DESIGN AND SETTING: Open randomized controlled trial in 17 medical-surgical ICUs. PATIENTS: Forty mechanically ventilated patients with early and refractory ARDS despite protective ventilation in the supine position. INTERVENTIONS: Patients were randomized to remain supine or be moved to early (within 48[Symbol: see text]h) and continuous (> or = 20 h/day) prone position until recovery or death. The trial was prematurely stopped due to a low patient recruitment rate. MEASUREMENTS AND RESULTS: Clinical characteristics, oxygenation, lung pressures, and hemodynamics were monitored. Need for sedation, complications, length of MV, ICU, and hospital stays, and outcome were recorded. PaO(2)/FIO(2) tended to be higher in prone than in supine patients after 6[Symbol: see text]h (202 +/-78 vs. 165+/-70 mmHg); this difference reached statistical significance on day 3 (234+/-85 vs. 159+/-78). Prone-related side effects were minimal and reversible. Sixty-day survival reached the targeted 15% absolute increase in prone patients (62% vs. 47%) but failed to reach significance due to the small sample. CONCLUSIONS: Our study adds data that reinforce the suggestion of a beneficial effect of early continuous prone positioning on survival in ARDS patients.

Outcome and prognostic factors in patients with hematologic malignancies admitted to the intensive care unit: a single-center experience.

Patients who are admitted to the intensive care unit (ICU) with hematologic malignancies have a poor prognosis, although outcomes have improved in recent years. This study analyzed ICU mortality, short- and long-term survival, and prognostic factors for 100 consecutive critically ill patients with a hematologic malignancy who were admitted to our polyvalent ICU from January 2000 to May 2006. The median age was 55 years (range, 15-75 years; male-female ratio, 60:40). The main acute life-threatening diseases precipitating ICU transfer were respiratory failure (45 patients, 45%) and septic shock (33 patients, 33%). Forty-two patients (42%) were discharged from the ICU. The ICU mortality rate from 2004 to 2006 was lower than from 2000 to 2003 (49% versus 69%, P < .047). The 1- and 2-year probabilities of survival for patients discharged from the ICU were 67% (95% confidence interval [CI], 51%-84%) and 54% (95% CI, 34%-73%), respectively. A multivariate analysis revealed hemodynamic instability (odds ratio, 2.11; 95% CI, 1.17-3.83; P = .014) and mechanical ventilation (odds ratio, 4.27; 95% CI, 1.70-10.74; P = .002) to be the main predictors of a poor survival prognosis. Almost half of patients with hematologic malignancy and life-threatening complications can be discharged from the ICU. Age and underlying disease characteristics do not influence ICU outcome, which is mainly determined by hemodynamic and ventilatory status.

Discrepancy between clinical criteria for diagnosing acute respiratory distress syndrome secondary to community acquired pneumonia with autopsy findings of diffuse alveolar damage.

Diffuse alveolar damage (DAD) is the underlying pathological finding in most cases of acute respiratory distress syndrome (ARDS). The objective of this study was to compare clinical criteria for ARDS secondary to community acquired pneumonia with autopsy findings of DAD and to determine the discrepancy rate between the two. We compared prospectively obtained clinical diagnosis of ARDS secondary to community acquired pneumonia with autopsy findings of DAD and pneumonia. Forty nine patients dead with a clinical diagnosis of ARDS secondary to pneumonia who underwent autopsy between 1986 and 2004 in our ICU were included with systematic histopathological analysis of all lung lobes. The discrepancy rate between the premortem clinical diagnosis of ARDS secondary to pneumonia and DAD at autopsy was determined. Seven patients were found to have neither infection nor DAD at autopsy. Six patients showed pathologic signs of DAD without evidence of infection. Out of 38 patients meeting clinical criteria for ARDS secondary to pneumonia and proven pneumonia at autopsy, 25 met criteria for DAD at autopsy. Therefore, 18 out of 49 patients who were clinically diagnosed with ARDS did not actually show pathological signs of DAD, resulting in a discrepancy rate of 37%. Despite an acceptable correspondence between clinical criteria for ARDS secondary to pneumonia and autopsy findings of DAD a significant number of patients had neither signs of DAD nor infection.

[Serious postoperative complications after esophagectomy for esophageal carcinoma: analysis of risk factors]. / Complicaciones postoperatorias graves tras esofagectomía para carcinoma esofágico: análisis de factores de riesgo.

INTRODUCTION: To identify risk factors for postoperative morbidity and mortality in patients undergoing esophagectomy for esophageal cancer. DESIGN AND PATIENTS: The population comprised 159 patients with locally advanced esophageal cancer, undergoing esophagectomy between January 1985 and December 2004. RESULTS: Infections were the main cause of both complications and postoperative mortality. The 54% of our patients presented serious complications. The mortality of the series was 12.5%. Multiorganic failure secondary to sepsis was the more frequent cause of death. The postoperative complications showed a significant association with: alcoholism (p < 0.04), hepatic cirrhosis (p < 0.03), the location of the tumor in middle third of the esophagus (p < 0.04), and the APACHE II score greater of 10 (p < 0.003). Mortality was associated significantly with the presence of chronic pulmonary disease (p = 0,03) and with an APACHE II score superior to 10 (p = 0,02). CONCLUSIONS: The APACHE II score superior to 10 can be used so much as prognostic factor of mortality like of serious complications. Chronic obstructive pulmonary disease is a risk factor for postoperative mortality. Alcoholism, hepatic cirrhosis and the location of the tumor, are factors associated to postoperative serious complications.