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.

[Treatment of acute myocardial infarction by primary angioplasty on-site compared with treatment following interhospital transfer: short- and long-time clinical outcomes]. / Tratamiento del infarto agudo de miocardio con angioplastia primaria in situ frente a transferencia interhospitalaria para su realización: resultados clínicos a corto y largo plazo.

INTRODUCTION AND OBJECTIVES: Primary angioplasty is the treatment of first choice for patients with ST-segment elevation acute myocardial infarction. However, its use is limited as the majority of patients present at hospitals without a catheterization laboratory. The objective of this study was to determine short- and long-term outcomes of systematically implementing a primary angioplasty program at two hospitals, one of which did not have a catheterization laboratory. METHODS: This prospective observational study involved consecutive patients with acute myocardial infarction and an indication for reperfusion therapy who were admitted to the two participating hospitals (Hospital 1 had a catheterization laboratory, while Hospital 2 did not) between January 2000 and April 2001. Clinical follow-up was performed at 1, 6 and 12 months. RESULTS: The study included 222 patients: 158 in Hospital 1 and 64 in Hospital 2. The median (interquartile range) delays from door to angiography at Hospital 1 and Hospital 2 were 49.5 min (30.0-88.0 min) and 62.5 min (53.5-93.7 min), respectively (P=.001), and from symptoms to angiography, 162.5 min (105.0-247.5 min) and 187.5 min (131.2-288.7 min), respectively (P=.04). In-hospital and 1-year mortality rates were 12.2% and 15.3%, respectively, with no difference between the hospitals. The hospital of origin was not a determinant of either in-hospital mortality (odds ratio [OR]=1.42, 95% confidence interval [CI], 0.3-7.8) or 1-year mortality (HR=2.04, 95% CI, 0.74-5.61). CONCLUSIONS: Patients with ST-segment elevation acute myocardial infarction who require interhospital transfer for primary angioplasty have a similar clinical outcome to those who are admitted to a hospital at which the procedure is available, provided transfer is undertaken under optimal conditions (i.e., with a suitable means of transport and a short transfer time).