Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study.

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

Prolonged high-frequency jet ventilation in a patient with bronchopleural fistula. An alternative mode of ventilation.

We report a case of bronchopleural fistula (BPF) in a patient submitted to conventional mechanical ventilation in which high frequency jet ventilation (HFJV) was applied during five consecutive days. Gas exchange was adequate, the bronchial secretions could easily be cleared and the patient adapted comfortably to HFJV. In spite of PEEP levels between 4 and 8 mm Hg, the leak through the BPF ceased completely.

Early evaluation of coagulase negative staphylococcus in blood samples of intensive care unit patients. A clinically uncertain judgement.

Of 2160 intensive care unit patients, 36 patients with positive blood cultures had coagulase-negative staphylococcus in one blood bottle, whereas the organism was present in two or more bottles in 38 cases. The groups were not significantly different in 27 clinical variables, obtained at the time of their first positive blood culture. There was also no significant difference in the antimicrobial sensitivities. No initial clinical data supported the classification of coagulase-negative staphylococcus as either pathogen or contaminant. When the 74 patients with blood culture positive coagulase-negative staphylococcus were compared with three "control groups" ("absent septicemia," "probable septicemia" and "proven septicemia") they were not different from those with "probable septicemia." A discriminant analysis was performed comparing patients with "absent septicemia" and with "proven septicemia" in an attempt to classify patients with isolates of coagulase-negative staphylococcus in one of these groups at an early stage. Patients with two or more positive blood cultures were not statistically classified more frequently as septicemic than patients with one blood bottle positive for this organism. However, patients categorized as septicemic had a significantly higher mortality (59%) than those classified as non-septicemic (35%) (p less than 0.05).

Sequential epidemic outbreaks of septicaemias by Serratia and Klebsiella species on a medical intensive care unit.

The high rate of septicaemias (20%, 19% and 14%) observed in our Intensive Care Unit (ICU) during the first 3 years was due to an epidemic incidence of Serratia sp. (S) (26% during the first year) and Klebsiella sp. (K) (25% during the third) and decreased significantly in the following 6 years (mean incidence of 11%) (p less than 0.01). During this epidemic phase these organisms were isolated quite frequently (between a 14% and a 6%) from all patients admitted. The K was more regularly present, for the mean time intervals free of its bacteriological presence were shorter (11 days) than those of S (27 days) (p less than 0.01). The K was isolated in more patients (160) than S (79) (p less than 0.01) and in more samples (360) than S (235) (p less than 0.01), but caused less secondary septicaemias per colonized patient (7% versus 29%) (p less than 0.01). In 59% of all S septicaemias the organism was previously isolated in other culture, while this was observed in only 34% of K septicaemias (x2 = 3.78, p = 0.052). The large variations in the incidence of septicaemias within our ICU, the appearance of sequential epidemic outbreaks, with a different behaviour of S and K and the individual risk of septicaemia of patients colonized by these organisms are noted.

[Prognostic value of 2 patient classification systems: APACHE II and diagnosis-related groups]. / Valor pronóstico de dos sistemas de clasificación de pacientes: APACHE II y grupos relacionados con el diagnóstico.

UNLABELLED: The APACHE II system classified patients on the basis of the severity of their disease, while the groups related with the diagnosis (DRG) are classified according to the consumption of resources. Nonetheless, the relative DRG weight (RWDRG) may be related with severity given that the most severe patients are also usually the most expensive. The aims of the study were: 1) verify the ability of DRG to measure clinical severity and 2) compare the prognostic value of both systems. METHODS: A transversal cut off was performed (316 consecutive admissions in intensive care units [ICU] with 23 exclusions due to unclear final evolution) with the patients being classified according to final hospital evolution in survivors and deaths. Each patient was given an APACHE II score corresponding to the first 24 hours in the ICU. Parallelly the cases were grouped in the corresponding DRG in accordance with the CIE-9-MC codification of their discharge report. The comparison of the means was carried out with the Student's t test, with the determination of prognostic values being performed by discriminant analysis. RESULTS: The survivors had an APACHE II score of 9.5 +/- 5.5 and the deaths of 22.5 +/- 7.8 (p < 0.0001). The RWDRG of the survivors was 1.4 +/- 0.9 and that of the deaths of 2.0 +/- 1.0 (p < 0.0001). On inclusion of all the patients the APACHE II prognostic value was 85.3% and the RWDRG 68.9% and both 84.6%. In the group of patients with a RWDRG lower than 1.6 the prognostic value of the APACHE II was of 87.6% and the RGRDW 72.0% and both 90%. In the group with RWDRG greater than 1.6 the prognostic value of the APACHE II was 85.1%, the RWDRG 73.0% and both 83.2%. CONCLUSIONS: The system of the groups related with diagnosis indirectly measures clinical severity. APACHE II is significantly superior to the system of groups related with diagnosis with regard to prognostic value. The use of both systems together does not improve the prognostic value of APACHE II.

[Pandemic influenza A in the ICU: experience in Spain and Latin America. GETGAG/SEMICYUC/(Spanish Working Group on Severe Pandemic Influenza A/SEMICYUC)]. / Gripe A pandémica en una unidad de cuidados intensivos: experiencia en España y Latinoamérica (Grupo Español de Trabajo de Gripe A Grave/Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias).

INTRODUCTION: Pandemic Influenza A (H1N1)v infection is the first pandemic in which intensive care units (ICU) play a fundamental role. It has spread very rapidly since the first cases were diagnosed in Mexico with the subsequent spread of the virus throughout the Southern Cone and Europe during the summer season. OBJECTIVE: This study has aimed to compare the clinical presentation and outcome among the critical patients admitted to the ICU until July 31, 2009 in Spain with some series from Latin America. MATERIAL AND METHOD: Six series of critically ill patients admitted to the ICU were considered. Clinical characteristics, complications and outcome were compared between series. RESULTS: Young patients (35-45 years) with viral pneumonia as a predominant ICU admission cause with severe respiratory failure and a high need of mechanical ventilation (60-100%) were affected. Obesity, pregnancy and chronic lung disease were risk factors associated with a worse outcome, however there was a high number of patients without comorbidities (40-50%). Mortality rate was between 25-50% and higher in the Latin America series, demonstrating the specific potential pathogenesis of the new virus. The use of antiviral treatment was delayed (between 3 and 6 days) and not generalized, with greater delay in Latin America in regards to Spain. CONCLUSIONS: These data suggest that a more aggressive treatment strategy, with earlier and easier access to the antiviral treatment might reduce the number of ICU admissions and mortality.

Simple and accurate monitoring of end-tidal carbon dioxide tensions during high-frequency jet ventilation.

To determine whether end-tidal carbon dioxide tension (PETCO2) accurately reflects PaCO2 during high-frequency jet ventilation (HFJV), 43 studies were performed on eight mongrel dogs with normal lungs. During HFJV, minute volume was modified to obtain a range of PaCO2 values from 15.5 to 74.5 torr. When PETCO2 was measured with an infrared gas analyzer, there was a poor correlation between PaCO2 and PETCO2 values. However, when the high-frequency ventilator was adjusted to deliver large tidal-volume (sigh) breaths, PETCO2 values were significantly (r = 0.94, p less than .001) correlated with PaCO2. Our data suggest that the PETCO2 of alveolar gas is an accurate indicator of the PaCO2 during HFJV in nondiseased lungs.

[Bacteremia associated with mycotic aneurysm of the transversal aortic arch and myocarditis caused by Salmonella enteritidis]. / Bacteriemia asociada a aneurisma micótico de arco aórtico transverso y miocarditis por Salmonella enteritidis.

A 60-year-old male with diabetes mellitus had Salmonella enteritidis bacteremia associated with mycotic aneurysm of the transverse aortic arc and myocarditis. Antibiotic therapy with ampicillin and chloramphenicol was ineffective despite the fact that the microorganism was sensitive in vitro to those antimicrobials, and the patient had a progressive clinical deterioration which culminated in death.