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1.
Crit Care ; 28(1): 199, 2024 06 14.
Artículo en Inglés | MEDLINE | ID: mdl-38877571

RESUMEN

Haemoglobin (Hb) thresholds and red blood cells (RBC) transfusion strategies in traumatic brain injury (TBI) are controversial. Our objective was to assess the association of Hb values with long-term outcomes in critically ill TBI patients. We conducted a secondary analysis of CENTER-TBI, a large multicentre, prospective, observational study of European TBI patients. All patients admitted to the Intensive Care Unit (ICU) with available haemoglobin data on admission and during the first week were included. During the first seven days, daily lowest haemoglobin values were considered either a continous variable or categorised as < 7.5 g/dL, between 7.5-9.5 and > 9.5 g/dL. Anaemia was defined as haemoglobin value < 9.5 g/dL. Transfusion practices were described as "restrictive" or "liberal" based on haemoglobin values before transfusion (e.g. < 7.5 g/dL or 7.5-9.5 g/dL). Our primary outcome was the Glasgow outcome scale extended (GOSE) at six months, defined as being unfavourable when < 5. Of 1590 included, 1231 had haemoglobin values available on admission. A mean Injury Severity Score (ISS) of 33 (SD 16), isolated TBI in 502 (40.7%) and a mean Hb value at ICU admission of 12.6 (SD 2.2) g/dL was observed. 121 (9.8%) patients had Hb < 9.5 g/dL, of whom 15 (1.2%) had Hb < 7.5 g/dL. 292 (18.4%) received at least one RBC transfusion with a median haemoglobin value before transfusion of 8.4 (IQR 7.7-8.5) g/dL. Considerable heterogeneity regarding threshold transfusion was observed among centres. In the multivariable logistic regression analysis, the increase of haemoglobin value was independently associated with the decrease in the occurrence of unfavourable neurological outcomes (OR 0.78; 95% CI 0.70-0.87). Congruous results were observed in patients with the lowest haemoglobin values within the first 7 days < 7.5 g/dL (OR 2.09; 95% CI 1.15-3.81) and those between 7.5 and 9.5 g/dL (OR 1.61; 95% CI 1.07-2.42) compared to haemoglobin values > 9.5 g/dL. Results were consistent when considering mortality at 6 months as an outcome. The increase of hemoglobin value was associated with the decrease of mortality (OR 0.88; 95% CI 0.76-1.00); haemoglobin values less than 7.5 g/dL was associated with an increase of mortality (OR 3.21; 95% CI 1.59-6.49). Anaemia was independently associated with long-term unfavourable neurological outcomes and mortality in critically ill TBI patients.Trial registration: CENTER-TBI is registered at ClinicalTrials.gov, NCT02210221, last update 2022-11-07.


Asunto(s)
Transfusión Sanguínea , Lesiones Traumáticas del Encéfalo , Enfermedad Crítica , Hemoglobinas , Unidades de Cuidados Intensivos , Humanos , Lesiones Traumáticas del Encéfalo/terapia , Lesiones Traumáticas del Encéfalo/sangre , Lesiones Traumáticas del Encéfalo/mortalidad , Lesiones Traumáticas del Encéfalo/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Hemoglobinas/análisis , Estudios Prospectivos , Enfermedad Crítica/terapia , Adulto , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/estadística & datos numéricos , Transfusión Sanguínea/métodos , Transfusión Sanguínea/estadística & datos numéricos , Anciano , Anemia/terapia , Anemia/sangre , Resultado del Tratamiento , Escala de Consecuencias de Glasgow , Transfusión de Eritrocitos/métodos , Transfusión de Eritrocitos/estadística & datos numéricos
2.
Intensive Care Med ; 49(1): 50-61, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36622462

RESUMEN

PURPOSE: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six months mortality and neurological outcome. METHODS: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. RESULTS: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p < 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p < 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p < 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p < 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p < 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. CONCLUSIONS: During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six months mortality but not on neurological outcome.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Hipertensión Intracraneal , Humanos , Femenino , Persona de Mediana Edad , Masculino , Estudios Prospectivos , Presión Intracraneal , Unidades de Cuidados Intensivos , Monitoreo Fisiológico , Hipertensión Intracraneal/etiología , Hipertensión Intracraneal/terapia , Encéfalo , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/terapia , Escala de Coma de Glasgow
3.
Neurocrit Care ; 38(3): 741-751, 2023 06.
Artículo en Inglés | MEDLINE | ID: mdl-36471182

RESUMEN

BACKGROUND: Intracranial pressure (ICP) monitoring and its management in aneurysmal subarachnoid hemorrhage (aSAH) is variable worldwide. The present study aimed to explore the practice of ICP monitoring, its variability across countries, and the association with 6-month outcomes in aSAH. METHODS: This was a preplanned subanalysis of SYNAPSE-ICU, a multicenter, international, prospective, observational cohort study focused on patients diagnosed with aSAH. We evaluated the variability in ICP monitoring across countries through a logistic regression model adjusted for case-mix and considered countries as a random effect. The association between ICP probe insertion and 6-month mortality and a poor neurological outcome, defined as an Glasgow Outcome Score Extended ≤ 4, was assessed by using a propensity score approach. RESULTS: A total of 423 patients with aSAH from 92 centers across 32 countries were included in this analysis. ICP monitoring was used in 295 (69.7%) patients. Significant between-country variability in ICP insertion was observed, with an incidence ranging between 4.7% and 79.9% (median odd ratio 3.04). The median duration of ICP monitoring was 12 days (first quartile [Q1] through third quartile [Q3] range 8-18), with an overall daily median ICP value of 14 mm Hg (Q1-Q3 10-19) and a median maximum value of 21 mm Hg (Q1-Q3 16-30). Patients monitored with ICP received more aggressive therapy treatments compared with non-monitored patients (therapy intensity level, TIL, score 10.33 [standard deviation 3.61] vs. 6.3 [standard deviation 4.19], p < 0.001). In more severe patients, ICP monitoring was significantly associated with better 6-month outcome (poor neurological outcome: odds ratio 0.14, 95% confidence interval 0.02-0.53, p = 0.0113; mortality: hazard ratio 0.25, 95% confidence interval 0.13-0.49, p < 0.0001). However, no significant effect was observed in patients with both reactive pupils. CONCLUSIONS: Our cohort demonstrated high variability in ICP insertion practice among countries. A more aggressive treatment approach was applied in ICP-monitored patients. In patients with severe aSAH, ICP monitoring might reduce unfavorable outcomes and mortality at 6 months.


Asunto(s)
Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/etiología , Resultado del Tratamiento , Presión Intracraneal , Estudios Prospectivos , Monitoreo Fisiológico
4.
ASAIO J ; 69(4): 360-365, 2023 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-36229029

RESUMEN

Patients receiving extracorporeal membrane oxygenation (ECMO) often suffer from acute kidney injury (AKI), requiring continuous renal replacement therapy (CRRT). In our clinical practice, we connected the inlet line of a CRRT machine to the postoxygenator Luer port and the outlet line to the inlet Luer port of the oxygenator. In this case series, we analyzed the interaction between the two machines. Between December 31, 2017, and December 31, 2019, we enrolled 15 patients from the ICU of the San Matteo Hospital, Pavia, Italy. All of them suffered from severe acute respiratory distress syndrome and AKI stage 3. We analyzed 570 hours of CRRT combined with venovenous ECMO and collected 261,751 CRRT data. No discontinuation of CRRT occurred before 48 hours. Most of the alarms occurred within 24 hours of the connection: 22/10,831 (0.2%) showed an outranged inlet pressure, 11/10831 (0.11%) showed an outranged transmembrane pressure, 14/10,831 (0.13%) showed an outranged inlet pressure, and 138/10,831 (1.27%) an outranged effluent pressure. The rate per minute set for the ECMO circuit was correlated with the inlet (ß = 5.38; CI, 95% 1.42-9.35; p = 0.008), transmembrane (ß = 4.6; CI, 95% 1.97-7.24; p = 0.001), effluent (ß = 3.02; CI, 95% 1.15-4.90; p = 0.002), and outlet pressures (ß = 597; CI, 95% 2.31-9.63; p = 0.001) of the CRRT circuit. We reported that our configuration could be safe and effective, however well-designed studies would be beneficial for determining the potential risks and benefits.


Asunto(s)
Lesión Renal Aguda , Terapia de Reemplazo Renal Continuo , Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Humanos , Oxigenación por Membrana Extracorpórea/efectos adversos , Lesión Renal Aguda/terapia , Italia , Terapia de Reemplazo Renal , Estudios Retrospectivos
5.
Blood Purif ; 51(11): 912-922, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35263746

RESUMEN

INTRODUCTION: At the time of renal replacement therapy, approximately 20% of critically ill patients have septic shock. In this study, medium cutoff (MCO) continuous venovenous hemodialysis (CVVHD) was compared to high-flux membrane continuous venovenous hemodiafiltration (CVVHDF) in terms of hemodynamic improvement, efficiency, middle molecule removal, and inflammatory system activation. METHODS: This is a monocenter crossover randomized study. Between December 31, 2017, and December 31, 2019, 20 patients with septic shock and stage 3 acute kidney injury (AKI) admitted to 2 Italian ICUs were enrolled. All patients underwent CVVHD with Ultraflux® EMiC®2 and CVVHDF with AV1000S® without washout. Each treatment lasted 24 h. RESULTS: Compared to AV1000S®-CVVHDF, EMIC®2-CVVHD normalized cardiac index (ß = -0.64; p = 0.02) and heart rate (ß = 5.72; p = 0.01). Interleukin-8 and myeloperoxidase removal were greater with AV1000S®-CVVHDF than with EMiC®2-CVVHD (ß = 0.35; p < 0.001; ß = 0.43; p = 0.03, respectively). Leukocytosis improved over 24 h in EMiC®2-CVVHD-treated patients (ß = 4.13; p = 0.03), whereas procalcitonin levels decreased regardless of the modality (ß = 0.89; p = 0.01) over a 48-h treatment period. Reduction rates, instantaneous plasmatic clearance of urea, creatinine, and ß2-microglobulin were similar across modalities. ß2-Microglobulin removal efficacy was greater in the EMiC®2 group (ß = 0-2.88; p = 0.002), while albumin levels did not differ. Albumin was undetectable in the effluent in both treatments. DISCUSSION: In patients with septic shock and severe AKI, the efficacy of uremic toxin removal was comparable between MCO-CVVHD and CVVHDF. Further, MCO-CVVHD was associated with improved hemodynamics. Fraction of filtration and transmembrane pressure reduction and the maintenance of equal efficacy might be the key features of CVVHD with MCO membranes in critically ill patients.


Asunto(s)
Lesión Renal Aguda , Terapia de Reemplazo Renal Continuo , Hemodiafiltración , Choque Séptico , Humanos , Choque Séptico/terapia , Choque Séptico/etiología , Enfermedad Crítica , Diálisis Renal , Lesión Renal Aguda/terapia , Albúminas , Hemodiafiltración/efectos adversos
7.
Curr Opin Crit Care ; 28(2): 166-175, 2022 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-35081556

RESUMEN

PURPOSE OF REVIEW: To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI). RECENT FINDINGS: Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients. SUMMARY: The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Fragilidad , Anciano , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/terapia , Comorbilidad , Anciano Frágil , Fragilidad/epidemiología , Evaluación Geriátrica , Humanos , Pandemias
8.
Phlebology ; 36(10): 835-840, 2021 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-34212790

RESUMEN

OBJECTIVE: The aim of our study was to analyze the specificity, accuracy and sensitivity of a simple, easy to calculate, prognostic score for hospitalized COVID19 patients developing deep vein thrombosis. METHODS: From March 1st to April 28th, 942 COVID-19 patients with severe symptoms were admitted to the hospital San Matteo of Pavia-Italy. Thirty two patients (3.4%) developed deep vein thrombosis during hospitalization. In all patients hemostatic and inflammatory parameters were abnormal. A simple prognostic score was developed based on the presence of specific co morbidities and D-dimers levels (quick San Matthew Score-quick SMS). RESULTS: Nine patients died in a condition of multiple organ failure, 23 patients (71.9%) survived and left the hospital in good general conditions. The developed score was based simply on two parameters: 1) presence of four specific co morbidities and 2)systemic levels of D-Dimers. The quick San Matthew Score resulted in a sensitivity, specificity and overall accuracy of more than 90% (94%, 92%,93% respectively) and compared favorably with other scores. The score was prospectively validated in 100 COVID19 patients who developed deep vein thrombosis collected from the literature and prospectively confirmed in our hospital. CONCLUSIONS: The findings of our study underline the importance of an immediate aggressive therapeutic approach for moderate and high-risk patients with COVID19 infection. The quick SMS score may help to identify patients at high risk for mortality and to follow the clinical outcome of the patient. A simple, easy to calculate prognostic score may also facilitate communication among health workers.


Asunto(s)
COVID-19 , Trombosis de la Vena , Hospitalización , Humanos , Pronóstico , SARS-CoV-2 , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/epidemiología , Trombosis de la Vena/terapia
9.
Minerva Anestesiol ; 86(11): 1214-1233, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32755094

RESUMEN

In December 2019, Coronavirus disease 2019 (COVID-19) emerged in Wuhan and rapidly spread around the word. The immune response is essential to control and eliminate CoV infections, however, multiorgan damage might be due to direct SARS-CoV2 action against the infected organ cells, as well as an imbalanced host immune response. In effect, a "cytokines storm" and an impaired innate immunity were found in the COVID-19 critically ill patients. In this review, we summarized the virus immune response steps, underlying the relevance of introducing the measurement of plasma cytokine levels and of circulating lymphocyte subsets in clinical practice for the follow-up of critically ill COVID-19 patients and support new therapy.


Asunto(s)
COVID-19/inmunología , COVID-19/terapia , Inmunidad Adaptativa , Cuidados Críticos , Enfermedad Crítica , Síndrome de Liberación de Citoquinas , Humanos , Inmunidad Innata , Inmunoterapia
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