Caracterización demográfica y clínica de pacientes críticos con neumonía por influenza A H1N1 / Demographic and clinical characterization of critically ill patients with influenza A H1N1 pneumonia

INTRODUCCIÓN. La epidemia de influenza y sus complicaciones profundizaron el estudio de las neumonías virales en cuidados intensivos. En nuestro país hay pocos datos sobre este tema. OBJETIVOS. Realizar una caracterización demográfica y clínica de pacientes críticos con neumonía por Influenza A H1N1 en un hospital de tercer nivel de complejidad. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, con análisis univariante y multivariante. Población de 293 y muestra de 44 datos de historias clínicas electrónicas de pacientes diagnosticados con A H1N1 ingresados a la Unidad de cuidados intensivos del Hospital de Especialidades Carlos Andrade Marín en el período enero 2016 a diciembre de 2018. Como criterios de inclusión se consideró a todos los pacientes adultos mayores de 18 años que ingresaron a la UCI, con el diagnóstico de neumonía comunitaria grave con confirmación por reacción de cadena de polimerasa en tiempo real para influenza A H1N1 en hisopado nasal o aspirado traqueal. Se excluyó a pacientes embarazadas con diagnóstico de influenza A H1N1, pacientes con más de 48 horas de ingreso hospitalario previo a su ingreso a UCI, pacientes con datos insuficientes en los registros. Los datos se obtuvieron del sistema AS-400. El análisis estadístico se realizó en el programa Statistical Package for Social Sciences, versión 22. El nivel de significación fue una p<0.05. RESULTADOS. La prevalencia en pacientes críticos de neumonía por influenza A H1N1 durante 2016-2018 fue de 16,72%, la mediana de edad fue de 55 años, 25% masculinos, 34% obesos, 34% con hipertensión arterial. Escala "Acute Physiology and Chronic Health Evaluation II" 23,50, "Simplified Acute Physiologic Score III" 54, "Sepsis related Organ Failure Assessment" 11,50, Lactato deshidrogenasa 99,50, Procalcitonina 0,99; 9 días de ventilación mecánica invasiva, 10,50 días de estancia en la unidad. El 91% presentó shock séptico, 59% lesión renal aguda. El 89% tuvo Síndrome de Distrés Respiratorio del Adultos, 69% fue grave, 87% usó ventilación mecánica, 38,50% corticoides, 36% posición prona, Presión parcial de oxígeno/Fracción inspirada de oxígeno 74, volumen tidal/kilogramo de 7 mililitros, presión plateau de 27,50 centímetros de agua. La mortalidad general en la Unidad de Cuidados Intensivos fue de 38,63% y a los 28 días de 63,60%, en shock séptico fue 42,50% y en Síndrome de Distrés Respiratorio del Adultos del 41,02%. El análisis de regresión logística multivariable identificó como factores independientes asociados a mortalidad el incremento de Lactato deshidrogenasa (OR 2,69, 9% IC 1,090-6,642) y Procalcitonina (OR 2,51, IC 1,005-6,272). CONCLUSIONES. Las características, frecuencia y mortalidad de este grupo de pacientes críticos con neumonía por influenza A H1N1 son similares a lo reportado en la literatura mundial.

INTRODUCTION. The influenza epidemic and its complications deepened the study of viral pneumonias in intensive care. In our country there is little data on this subject. OBJECTIVES. To perform a demographic and clinical characterization of critical patients with pneumonia due to pneumonia due to Influenza A H1N1 in a third level hospital. MATERIALS AND METHODS. Observational, analytical, retrospective study, with univariate and multivariate analysis. We compared the groups of dead patients and survivors. The significance level was p<0,05. RESULTS. The prevalence in critically ill patients of influenza A H1N1 pneumonia during 2016-2018 was 16,72%, 44 cases were collected, median age 55 years, 25% male, 34% obese, 34% with arterial hypertension. APACHE II 23,50, SAPS III 54, SOFA 11,50, LDH 99,50, PCT 0,99, 9 days of invasive mechanical ventilation, 10,50 days of unit stay. 91% presented septic shock, 59% with acute kidney injury 89% had ARDS, 69% were severe, 87% used mechanical ventilation, 38,50% corticosteroids, 36% prone position, PaO2/FiO2 74, tidal volume/kg of 7 ml, plateau pressure of 27,50 cmH2O. Overall mortality in the ICU was 38,63% and at 28 days was 63,60%, in septic shock it was 42,50% and in Adult Respiratory Distress Syndrome it was 42,50%. was 42,50% and 41,02% in Adult Respiratory Distress Syndrome. The ultivariate logistic regression analysis identified as independent factors associated with mortality, the increase in LDH (OR 2,69, 9% CI 1,090-6,642) and PCT (OR 2,51, CI 1,005-6,272). CONCLUSIONS. The characteristics, frequency and mortality of this group of critical patients with pneumonia due to influenza A H1N1 are similar to those reported in the world literature.

Resting Energy Expenditure of Patients on Venovenous Extracorporeal Membrane Oxygenation for Adult Respiratory Distress Syndrome: A Pilot Study.

OBJECTIVES: The objectives of this study were to 1) in patients without pulmonary function, determine resting energy expenditure (REE) in venovenous extracorporeal membrane oxygenation (ECMO) acute respiratory distress syndrome (ARDS) patients by paralysis status and 2) determine the threshold tidal volume (TV) associated with meaningful gas exchange as determined by measurable end-tidal carbon dioxide elimination (etV̇co2). DESIGN: Retrospective observational study. SETTING: A tertiary high ECMO volume academic institution. PATIENTS/SUBJECTS: Ten adult ARDS patients on venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The modified Weir equation, Fick principle, Henderson-Hasselbalch equation, ECMO flow, hemoglobin, and pre and post oxygenator blood gases were used to determine ECMO carbon dioxide production (V̇co2), ECMO oxygen consumption, and REE. REE values were matched to patients' paralysis status based on medication flowsheets and compared using a paired t test. Linear regression was performed to determine the threshold TV normalized to ideal body weight (IBW) associated with measurable ventilator etV̇co2, above which meaningful ventilation occurs. When lungs were not functioning, patients had significantly lower mean REE when paralyzed (23.4 ± 2.8 kcal/kg/d) than when not paralyzed (29.2 ± 5.8 kcal/kg/d) (p = 0.02). Furthermore, mean REE was not similar between patients and varied as much as 1.7 times between patients when paralyzed and as much as 1.4 times when not paralyzed. Linear regression showed that ventilator V̇co2 was measurable and increased linearly when TV was greater than or equal to 0.7 mL/kg. CONCLUSIONS: REE is patient-specific and varies significantly with and without patient paralysis. When TV exceeds 0.7 mL/kg IBW, ventilator V̇co2 increases measurably and must be considered in determining total REE.

Presentaciones inesperadas de enfermedades endémicas: síndrome de dificultad respiratoria aguda en un paciente con dengue / Unexpected presentations of endemic conditions: acute respiratory distress syndrome in a dengue patient

El dengue es la infección trasmitida por vectores con mayor impacto en carga de enfermedad, económica y social a nivel mundial, con más de 3,6 billones de personas en riesgo de infección. Sus manifestaciones son variables, caracterizadas en su mayoría por síndrome febril con riesgo de sangrado, choque y muerte. El compromiso pulmonar es infrecuente, siendo el síndrome de dificultad respiratoria aguda una complicación inesperada, aunque informada, asociada a un mal pronóstico. Se presenta un paciente sin antecedentes relevantes de importancia, con focalización pulmonar severa asociado a infección por el virus dengue. En el caso presentado se descartaron procesos infecciosos bacterianos u otros agentes causales de síndrome de dificultad respiratoria aguda, lo que sumado a las características clínicas de ingreso, zona de ocurrencia del caso considerada como endémica, curso clínico, paraclínico y la franca positividad de las pruebas para dengue así como la seroconversión de estas, a pesar de no haber sido realizadas pruebas moleculares, se consideró como el agente causal más probable el virus dengue. Todo esto lleva a recomendar siempre considerarlo como potencial agente causal, lo que permite así un diagnóstico y manejo óptimos(AU)

Dengue is the vector-borne infection with the greatest impact on disease, economic and social burden worldwide, with more than 3.6 billion people under risk of contagion. Its manifestations are varied, most of them characterized by febrile syndrome with a risk of bleeding, shock and death. Pulmonary involvement is infrequent, and acute respiratory distress syndrome is an unexpected complication, though it has been reported in association to a bad prognosis. A case is presented of a male patient without relevant antecedents of interest, with severe pulmonary focalization associated to dengue virus infection. Bacterial infectious processes and other causative agents of acute respiratory distress syndrome were ruled out. In view of the patient's clinical status at admission, the endemicity of the patient's area of residence, the clinical and paraclinical course, and the obvious positivity of the dengue tests performed and their seroconversion, despite not having conducted molecular tests, it was concluded that the most probable causative agent was dengue virus. Therefore, it is recommended that dengue infection always be considered as a potential causative agent of acute respiratory distress syndrome, thus contributing to optimal diagnosis and management(AU)

Effectiveness, Safety, and Economic Comparison of Inhaled Epoprostenol Brands, Flolan and Veletri, in Acute Respiratory Distress Syndrome.

Background: No previous studies exist examining 2 inhaled epoprostenol formulations in an acute respiratory distress syndrome (ARDS) patient population. Objective: The study aim was to evaluate a formulary conversion from inhaled Flolan to Veletri to determine the impact on effectiveness, safety, and cost in patients with ARDS. Methods: This was a single-center, retrospective, matched cohort observational study at a tertiary care academic medical center. Patients included were mechanically ventilated, adult patients with ARDS receiving inhaled Flolan or Veletri for ≥1 hour in the intensive care unit. Results: A total of 132 patients were included in the matched cohort. There was no difference detected in change in partial pressure of arterial O2/fraction of inspired O2 (PaO2/FiO2) ratio after 1 hour of therapy between the inhaled Flolan and Veletri groups (27.2 ± 46.2 vs 30 ± 68 mm Hg, P = 0.78). Significant differences in secondary outcomes included incidence of hypotension (83% vs 95.5%, P = 0.04) and thrombocytopenia (9.1% vs 29.5%, P < 0.01) in the inhaled Flolan and Veletri groups, respectively, with no difference in cost per duration of therapy (P = 0.29). Conclusions and Relevance: There was no difference in the change in PaO2/FiO2 ratio after 1 hour of therapy between inhaled Flolan and Veletri in an ARDS patient population. The formulary conversion from inhaled Flolan to Veletri was likely justified.

High lactate levels are predictors of major complications after cardiac surgery.

OBJECTIVE: Although hyperlactatemia after cardiac surgery is common, the implications of raised levels remain controversial. The aim of this study was to evaluate whether high lactate levels after cardiac surgery are predictors of major complications including mortality. PATIENTS AND METHODS: This was a substudy of TRACS (Transfusion Requirements After Cardiac Surgery), which was designed as a prospective, randomized, controlled trial evaluating the effects of a transfusion strategy on morbidity and mortality. RESULTS: Of the 502 patients enrolled, 52 (10%) had at least 1 major complication. Patients with complications were older, had a higher EuroSCORE, lower left ventricular ejection fraction, lower preoperative hemoglobin, a higher prevalence of renal disease, and received more blood transfusions than the group without complications. Lactate levels were higher in the group with complications at the end of surgery (3.6 mmol/L [2.8-5.1] vs 3.3 mmol/L [2.2-4.8]; P = .018), immediately after intensive care unit (ICU) admission (0 hour) (4.4 mmol/L [3.1-8.4] vs 4 mmol/L [2.6-6.4]; P = .048); 6 hours (4 mmol/L [2.7-5.8] vs 2.6 mmol/L [2-3.6], P < .001), and 12 hours after admission (2.3 mmol/L [1.8-3.2] vs 1.7 mmol/L [1.3-2]; P < .001). In a multivariate model, higher age (odds ratio [OR], 1.048, 95% confidence interval [CI], 1.011-1.086; P = .010), left ventricular ejection fraction (LVEF) lower than 40% (OR, 3.03; 95% CI, 1.200-7.510; P = .019 compared with LVEF of 40%-59%; OR, 3.571; 95% CI, 1.503-8.196; P = .004 compared with LVEF higher than 60%), higher EuroSCORE (OR, 1.138; 95% CI; 1.007-1.285; P = .038), red blood cell transfusion (OR, 1.230; 95% CI, 1.086-1.393; P = .001), and lactate levels 6 hours after ICU admission (OR, 3.28, 95% CI; 1.61-6.69; P = .001) are predictors of major complications. CONCLUSIONS: Hyperlactatemia 6 hours after ICU admission is an independent risk factor for worse outcomes in adult patients after cardiac surgery.