Volume Infusion Markedly Increases Femoral dP/dtmax in Fluid-Responsive Patients Only.

OBJECTIVES: To evaluate the preload dependence of femoral maximal change in pressure over time (dP/dtmax) during volume expansion in preload dependent and independent critically ill patients. DESIGN: Retrospective database analysis. SETTING: Two adult polyvalent ICUs. PATIENTS: Twenty-five critically ill patients with acute circulatory failure. INTERVENTIONS: Thirty-five fluid infusions of 500 mL normal saline. MEASUREMENTS AND MAIN RESULTS: Changes in femoral dP/dtmax, systolic, diastolic, and pulse femoral arterial pressure were obtained from the pressure waveform analysis using the PiCCO2 system (Pulsion Medical Systems, Feldkirchen, Germany). Stroke volume index was obtained by transpulmonary thermodilution. Statistical analysis was performed comparing results before and after volume expansion and according to the presence or absence of preload dependence (increases in stroke volume index ≥ 15%). Femoral dP/dtmax increased by 46% after fluid infusion in preload-dependent cases (mean change = 510.6 mm Hg·s; p = 0.005) and remained stable in preload-independent ones (mean change = 49.2 mm Hg·s; p = 0.114). Fluid-induced changes in femoral dP/dtmax correlated with fluid-induced changes in stroke volume index in preload-dependent cases (r = 0.618; p = 0.032), but not in preload-independent ones. Femoral dP/dtmax strongly correlated with pulse and systolic arterial pressures and with total arterial stiffness, regardless of the preload dependence status (r > 0.9 and p < 0.001 in all cases). CONCLUSIONS: Femoral dP/dtmax increased with volume expansion in case of preload dependence but not in case of preload independence and was strongly related to pulse pressure and total arterial stiffness regardless of preload dependence status. Therefore, femoral dP/dtmax is not a load-independent marker of left ventricular contractility and should be not used to track contractility in critically ill patients.

Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock.

INTRODUCTION: Since normal or high central venous oxygen saturation (ScvO2) values cannot discriminate if tissue perfusion is adequate, integrating other markers of tissue hypoxia, such as central venous-to-arterial carbon dioxide difference (PcvaCO2 gap) has been proposed. In the present study, we aimed to evaluate the ability of the PcvaCO2 gap and the PcvaCO2/arterial-venous oxygen content difference ratio (PcvaCO2/CavO2) to predict lactate evolution in septic shock. METHODS: Observational study. Septic shock patients within the first 24 hours of ICU admission. After restoration of mean arterial pressure, and central venous oxygen saturation, the PcvaCO2 gap and the PcvaCO2/CavO2 ratio were calculated. Consecutive arterial and central venous blood samples were obtained for each patient within 24 hours. Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value. RESULTS: Thirty-five septic shock patients were studied. At inclusion, the PcvaCO2 gap was 5.6 ± 2.1 mmHg, and the PcvaCO2/CavO2 ratio was 1.6 ± 0.7 mmHg · dL/mL O2. Those patients whose lactate values did not decrease had higher PcvaCO2/CavO2 ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02). During the follow-up, 97 paired blood samples were obtained. No-improvement in lactate values was associated to higher PcvaCO2/CavO2 ratio values in the previous control. The ROC analysis showed an AUC 0.82 (p < 0.001), and a PcvaCO2/CavO2 ratio cut-off value of 1.4 mmHg · dL/mL O2 showed sensitivity 0.80 and specificity 0.75 for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (p < 0.001) in those patients with an elevated PcvaCO2/CavO2 ratio (≥1.4). CONCLUSION: In a population of septic shock patients with normalized MAP and ScvO2, the presence of elevated PcvaCO2/CavO2 ratio significantly reduced the odds of adequate lactate clearance during the following hours.

Thenar oxygen saturation during weaning from mechanical ventilation: an observational study.

Our aim was to determine whether thenar tissue oxygen saturation (S(tO2)), measured by noninvasive near-infrared spectroscopy, and its changes derived from an ischaemic challenge are associated with weaning outcome. Our study comprised a prospective observational study in a 26-bed medical-surgical intensive care unit. Patients receiving mechanical ventilation for >48 h, and considered ready to wean by their physicians underwent a 30-min weaning trial. S(tO2) was measured continuously on the thenar eminence. A transient vascular occlusion test was performed prior to and at the end of the 30-min weaning trial, in order to obtain S(tO2) deoxygenation and reoxygenation rates, and estimated local oxygen consumption. 37 patients were studied. Patients were classified as weaning success (n=24) or weaning failure (n=13). No significant demographic, respiratory or haemodynamic differences were observed between the groups at inclusion. Patients who failed the overall weaning process showed a significant increase in deoxygenation and in local oxygen consumption from baseline to 30 min of weaning trial, whereas no significant changes were observed in the weaning success group. Failure to wean from mechanical ventilation was associated with higher relative increases in deoxygenation after 30 min of spontaneous ventilation.

Multimorbidity patterns in COVID-19 patients and their relationship with infection severity: MRisk-COVID study.

BACKGROUND: Several chronic conditions have been identified as risk factors for severe COVID-19 infection, yet the implications of multimorbidity need to be explored. The objective of this study was to establish multimorbidity clusters from a cohort of COVID-19 patients and assess their relationship with infection severity/mortality. METHODS: The MRisk-COVID Big Data study included 14 286 COVID-19 patients of the first wave in a Spanish region. The cohort was stratified by age and sex. Multimorbid individuals were subjected to a fuzzy c-means cluster analysis in order to identify multimorbidity clusters within each stratum. Bivariate analyses were performed to assess the relationship between severity/mortality and age, sex, and multimorbidity clusters. RESULTS: Severe infection was reported in 9.5% (95% CI: 9.0-9.9) of the patients, and death occurred in 3.9% (95% CI: 3.6-4.2). We identified multimorbidity clusters related to severity/mortality in most age groups from 21 to 65 years. In males, the cluster with highest percentage of severity/mortality was Heart-liver-gastrointestinal (81-90 years, 34.1% severity, 29.5% mortality). In females, the clusters with the highest percentage of severity/mortality were Diabetes-cardiovascular (81-95 years, 22.5% severity) and Psychogeriatric (81-95 years, 16.0% mortality). CONCLUSION: This study characterized several multimorbidity clusters in COVID-19 patients based on sex and age, some of which were found to be associated with higher rates of infection severity/mortality, particularly in younger individuals. Further research is encouraged to ascertain the role of specific multimorbidity patterns on infection prognosis and identify the most vulnerable morbidity profiles in the community. TRIAL REGISTRATION: NCT04981249. Registered 4 August 2021 (retrospectively registered).

Thenar oxygen saturation (StO2) alterations during a spontaneous breathing trial predict extubation failure.

BACKGROUND: Weaning from mechanical ventilation (MV) is a cardiovascular stress test. Monitoring the regional oxygenation status has shown promising results in predicting the tolerance to spontaneously breathe in the process of weaning from MV. Our aim was to determine whether changes in skeletal muscle oxygen saturation (StO2) measured by near-infrared spectroscopy (NIRS) on the thenar eminence during a vascular occlusion test (VOT) can be used to predict extubation failure from mechanical ventilation. METHODS: We prospectively studied 206 adult patients with acute respiratory failure receiving MV for at least 48 h from a 30-bed mixed ICU, who were deemed ready to wean by their physicians. Patients underwent a 30-min spontaneous breathing trial (SBT), and were extubated according to the local protocol. Continuous StO2 was measured non-invasively on the thenar eminence. A VOT was performed prior to and at 30 min of the SBT (SBT30). The rate of StO2 deoxygenation (DeO2), StO2 reoxygenation (ReO2) rate and StO2 hyperemic response to ischemia (HAUC) were calculated. RESULTS: Thirty-six of the 206 patients (17%) failed their SBT. The remainder 170 patients (83%) were extubated. Twenty-three of these patients (13.5%) needed reinstitution of MV within 24 h. Reintubated patients displayed a lower HAUC at baseline, and higher relative changes in their StO2 deoxygenation rate between baseline and SBT30 (DeO2 Ratio). A logistic regression-derived StO2 score, combining baseline StO2, HAUC and DeO2 ratio, showed an AUC of 0.84 (95% CI 0.74-0.91) for prediction of extubation failure. CONCLUSIONS: Extubation failure was associated to baseline and dynamic StO2 alterations during the SBT. Monitoring StO2-derived parameters might be useful in predicting extubation outcome.

[III Catalan registry of ST elevation acute myocardial infarction. Comparison with former Catalan registries I and II from Catalonia, Spain]. / Resultados del III registro IAM CAT de pacientes con infarto de miocardio con elevación del segmento ST en Cataluña. Comparación con los registros IAM CAT I y II.

BACKGROUND AND OBJECTIVE: To analyze the use of reperfusion therapy in patients with ST elevation myocardial infarction (STEMI) in Catalonia in a registry performed in 2006 (IAM CAT III) and its comparison with 2 previous registries PATIENTS AND METHODS: Frequency of reperfusion therapy and time intervals between symptom onset - reperfusion therapy were the principal variables investigated. The IAM CAT I (June-December 2000) included 1,450 patients, the IAM CAT II (October 2002-April 2003) 1,386, and the IAM CAT III (October-December 2006) 367. RESULTS: The proportion of patients treated with reperfusion increased progressively (72%, 79% and 81%) as the use of primary angioplasty (5%, 10% and 33%). In the III registry the transfer system most frequently used was the SEM/061 (17%, 32% and 47%, respectively) but the time interval symptom onset-first contact with the medical system did not improve (II, 90 vs III, 105 min), the interval symptom onset-thrombolytic therapy did hardly change (178, 165 and 177 min) and the interval hospital arrival-trombolysis (needle-door) tended to improve (59, 42 and 42 min). Thirty day mortality in STEMI patients declined progressively through the 3 registries (12.1, 10.6 and 7.4%, p=0.012). CONCLUSIONS: The proportion of STEMI patients treated with reperfusion has improved but the interval to its application has not been shortened. To improve the latter it is mandatory an earlier contact with the medical system, a shortening of the intervals door-needle and door-balloon through better coordination between the 061, the sanitary personnel and the hospital administration, and to consider the subject as a real sanitary priority.

Influence of changes in ventricular systolic function and loading conditions on pulse contour analysis-derived femoral dP/dtmax.

BACKGROUND: Femoral dP/dtmax (maximum rate of the arterial pressure increase during systole) measured by pulse contour analysis has been proposed as a surrogate of left ventricular (LV) dP/dtmax and as an estimator of LV systolic function. However, femoral dP/dtmax may be influenced by LV loading conditions. In this study, we evaluated the impact of variations of LV systolic function, preload and afterload on femoral dP/dtmax in critically ill patients with cardiovascular failure to ascertain its reliability as a marker of LV systolic function. RESULTS: We performed a prospective observational study to evaluate changes in femoral dP/dtmax, thermodilution-derived variables (PiCCO2-Pulsion Medical Systems, Feldkirchen, Germany) and LV ejection fraction (LVEF) measured by transthoracic echocardiography during variations in dobutamine and norepinephrine doses and during volume expansion (VE) and passive leg raising (PLR). Correlations with arterial pulse and systolic pressure, effective arterial elastance, total arterial compliance and LVEF were also evaluated. In absolute values, femoral dP/dtmax deviated from baseline by 21% (201 ± 297 mmHg/s; p = 0.013) following variations in dobutamine dose (n = 17) and by 15% (177 ± 135 mmHg/s; p < 0.001) following norepinephrine dose changes (n = 29). Femoral dP/dtmax remained unchanged after VE and PLR (n = 24). Changes in femoral dP/dtmax were strongly correlated with changes in pulse pressure and systolic arterial pressure during dobutamine dose changes (R = 0.942 and 0.897, respectively), norepinephrine changes (R = 0.977 and 0.941, respectively) and VE or PLR (R = 0.924 and 0.897, respectively) (p < 0.05 in all cases). Changes in femoral dP/dtmax were correlated with changes in LVEF (R = 0.527) during dobutamine dose variations but also with effective arterial elastance and total arterial compliance in the norepinephrine group (R = 0.638 and R = - 0.689) (p < 0.05 in all cases). CONCLUSIONS: Pulse contour analysis-derived femoral dP/dtmax was not only influenced by LV systolic function but also and prominently by LV afterload and arterial waveform characteristics in patients with acute cardiovascular failure. These results suggest that femoral dP/dtmax calculated by pulse contour analysis is an unreliable estimate of LV systolic function during changes in LV afterload and arterial load by norepinephrine and directly linked to arterial waveform determinants.

Ward mortality in patients discharged from the ICU with tracheostomy may depend on patient's vulnerability.

OBJECTIVE: To determine the effect of discharge from the ICU with a tracheostomy tube on ward mortality and its relation to patient vulnerability. DESIGN AND SETTING: Retrospective single-center cohort study. METHODS: Database (2003-2006) review of patients undergoing mechanical ventilation (MV) > 24 h and discharged from the ICU with or without tracheostomy tube in place and followed up to hospital discharge or death. We recorded clinical characteristics, complications, major ICU procedures, subjective prognosis at ICU discharge (Sabadell score), and hospital outcome. Factors associated with ward mortality were analyzed by multiple logistic regression. RESULTS: From 3,065 patients admitted to the ICU, 1,502 needed MV > 24 h. Only 936 patients (62%) survived the ICU and were transferred to the ward; of these, 130 (13.9%) had a tracheostomy tube in place. Ward mortality was higher in patients with a tracheostomy tube in place than in those without (26 vs. 7%, P < 0.001). Increased ward mortality among cannulated patients was seen only in those with intermediate Sabadell score (24 vs. 9% in score 1, P = 0.02, and 38 vs. 24% in score 2, P = 0.06), but not in the "good prognosis" (2 vs. 2%, score 0) and "expected to die in hospital" (80 vs. 75%, score 3) groups. Multivariate analysis found three factors associated with ward mortality: age, tracheostomy tube in place, and Sabadell score. CONCLUSION: Lack of tracheostomy decannulation in the ICU appears to be associated with ward mortality, but only in the group with a Sabadell score of 1.

Noninvasive ventilation in patients with "do-not-intubate" orders: medium-term efficacy depends critically on patient selection.

OBJECTIVE: Randomized clinical trials demonstrating benefits of noninvasive ventilation (NIV) systematically exclude patients with "do-not-intubate" (DNI) orders, but in daily clinical practice these patients are frequently treated with NIV. A recent North American study found a 43% hospital survival rate in patients with DNI orders. Our hypothesis was that, due to the very different social and cultural setting, written DNI orders in a southern European country would be restricted to a population with a poor outcome, independently of whether they receive NIV, and we analyzed hospital survival in patients receiving NIV and the impact of DNI orders on survival. DESIGN AND SETTING: Retrospective cohort study in a general ICU in a university-affiliated hospital. PATIENTS AND METHODS: All 233 patients treated with NIV during 2002-2004. We recorded clinical characteristics on admission, mortality risk by APACHE II and ICU and hospital outcome, and 6-month outcome. RESULTS: Hospital survival was 66%. Survival was better in the 199 patients without DNI orders than in the 36 with DNI orders both during hospitalization (74% vs. 26%, OR 7.9) and after 6 months (64% vs. 15%, OR 10.2). In both groups the presence of COPD was associated with better prognosis during hospitalization, but not in the medium-term. CONCLUSION: Our study suggests that NIV offers low expectations for medium-term survival in DNI patients.

A modified McCabe score for stratification of patients after intensive care unit discharge: the Sabadell score.

INTRODUCTION: Mortality in the ward after an intensive care unit (ICU) stay is considered a quality parameter, and is described as a source of avoidable mortality. Additionally, the attending intensivist frequently anticipates fatal outcome after ICU discharge. Our objective was to test the ability of a new score to stratify patients according to ward mortality after ICU discharge. METHODS: A prospective cohort study was performed in the general ICU of a university-affiliated hospital. In 2003 and 2004 we prospectively recorded the attending intensivist's subjective prognosis at ICU discharge about the hospital outcome for each patient admitted to the ICU (the Sabadell score), which was later compared with the real hospital outcome. RESULTS: We studied 1,521 patients with a mean age of 60.2 +/- 17.8 years. The median (25-75% percentile) ICU stay was five (three to nine) days. The ICU mortality was 23.8%, with 1,156 patients being discharged to the ward. Post-ICU ward mortality was 9.6%, mainly observed in patients with a Sabadell score of 3 (81.3%) or a score of 2 (41.1%), whereas lower mortality was observed in patients scoring 1 (17.2%) and scoring 0 (1.7%). Multivariate analysis selected age and the Sabadell score as the only variables associated with ward mortality, with an area under the receiver operating curve of 0.88 (95% CI 0.84-0.93) for the Sabadell score. CONCLUSION: The Sabadell score at ICU discharge works effectively to stratify patients according to hospital outcome.

Thenar oxygen saturation and invasive oxygen delivery measurements in critically ill patients in early septic shock.

This prospective study was aimed to test the hypothesis that tissue hemoglobin oxygen saturation (StO2) measured noninvasively using near-infrared spectroscopy is a reliable indicator of global oxygen delivery (DO2) measured invasively using a pulmonary artery catheter (PAC) in patients with septic shock. The study setting was a 26-bed medical-surgical intensive care unit at a university hospital. Subjects were adult patients in septic shock who required PAC hemodynamic monitoring for resuscitation. Interventions included transient ischemic challenge on the forearm. After blood pressure normalization, hemodynamic and oximetric PAC variables and, simultaneously, steady-state StO2 and its changes from ischemic challenge (deoxygenation and reoxygenation rates) were measured. Fifteen patients were studied. All the patients had a mean arterial pressure above 65 mmHg. The DO2 index (iDO2) range in the studied population was 215 to 674 mL O2/min per m. The mean mixed venous oxygen saturation value was 61% ± 10%, mean cardiac index was 3.4 ± 0.9 L/min per m, and blood lactate level was 4.6 ± 2.7 mmol/L. Steady-state StO2 significantly correlated with iDO2, arterial and venous O2 content, and O2 extraction ratio. A StO2 cutoff value of 75% predicted iDO2 below 450, with a sensitivity of 0.9 and a specificity of 0.9. In patients in septic shock and normalized MAP, low StO2 reflects extremely low iDO2. Steady-state StO2 does not correlate with moderately low iDO2, indicating poor sensitivity of StO2 to rule out hypoperfusion.

Thenar oxygen saturation measured by near infrared spectroscopy as a noninvasive predictor of low central venous oxygen saturation in septic patients.

OBJECTIVE: To validate thenar oxygen saturation (StO(2)) measured by near-infrared spectroscopy (NIRS) as a noninvasive estimation of central venous saturation (ScvO(2)) in septic patients. DESIGN: Prospective observational study. SETTING: A 26-bed medical-surgical intensive care unit at a university-affiliated hospital. PATIENTS: Patients consecutively admitted to the ICU in the early phase of severe sepsis and septic shock, after normalization of blood pressure with fluids and/or vasoactive drugs. MEASUREMENTS: We recorded demographic data, severity score, hemodynamic data, and blood lactate, as well as ScvO(2), and StO(2) measured simultaneously on inclusion. Patients were divided into two groups according to ScvO(2) values: group A, with ScvO(2) < 70%, and group B, with ScvO(2) > or = 70%. RESULTS: Forty patients were studied. StO(2) was significantly lower in group A than in group B (74.7 +/- 13.0 vs. 83.3 +/- 6.2, P 0.018). No differences in age, severity score, hemodynamics, vasoactive drugs, or lactate were found between groups. Simultaneously measured ScvO(2) and StO(2) showed a significant Pearson correlation (r = 0.39, P 0.017). For a StO(2) value of 75%, sensitivity was 0.44, specificity 0.93, positive predictive value 0.92, and negative predictive value 0.52 for detecting ScvO(2) values lower than 70%. CONCLUSIONS: StO(2) correlates with ScvO(2) in normotensive patients with severe sepsis or septic shock. We propose a StO(2) cut-off value of 75% as a specific, rapid, noninvasive first step for detecting patients with low ScvO(2) values. Further studies are necessary to analyze the role of noninvasive StO(2) measurement in future resuscitation algorithms.

Resultados del III registro IAM CAT de pacientes con infarto de miocardio con elevación del segmento ST en Cataluña. Comparación con los registros IAM CAT I y II / III Catalan registry of ST elevation acute myocardial infarction. Comparison with former Catalan registries I and II from Catalonia, Spain

Fundamento y objetivo: Analizar el tratamiento de reperfusión en el infarto de miocardio (IAM) con elevación del segmento ST (IAMEST) en Cataluña en el registro realizado en el año 2006 (IAM CAT III) y su comparación con 2 registros previos. Pacientes y método: La frecuencia del tratamiento de reperfusión y los intervalos inicio de síntomas-tratamiento fueron las variables fundamentales. El IAM CAT I (junio-diciembre de 2000) incluyó 1.450 pacientes; el IAM CAT II (octubre de 2002-abril de 2003), 1.386, y el IAM CAT III (octubre-diciembre de 2006), 367. Resultados: La proporción de pacientes tratados con reperfusión fue progresivamente mayor (el 72, el 79 y el 81%, respectivamente) con aumento también progresivo de la angioplastia primaria (el 5, el 10 y el 33%, respectivamente). En el III se utilizó más frecuentemente el SEM/061 como transporte (el 17, el 32 y el 47%, respectivamente), pero el intervalo inicio de síntomas-contacto con el sistema sanitario no mejoró (90min en el II y 105 en el III). El intervalo inicio de síntomas-tratamiento trombolítico apenas se modificó (178, 165 y 177min, respectivamente) y sí lo hizo, parcialmente, el tiempo entrada al hospital-trombólisis (“puerta-aguja”) (59, 42 y 42min, respectivamente). La mortalidad a los 30 días del IAMEST descendió en el III registro (el 12,1, el 10,6 y el 7,4%, respectivamente; p=0,012). Conclusiones: La frecuencia de tratamiento de reperfusión en el IAMEST ha mejorado y es satisfactoria. Sin embargo, los intervalos de su aplicación apenas se han reducido. Para esto es preciso una notificación más precoz al sistema sanitario y una reducción de los tiempos “puerta-aguja” y “puerta-balón” mediante una actuación conjunta más coordinada del 061, el personal sanitario y la administración hospitalaria, así como una mayor prioridad en la política sanitaria (AU)

Background and objective: To analyze the use of reperfusion therapy in patients with ST elevation myocardial infarction (STEMI) in Catalonia in a registry performed in 2006 (IAM CAT III) and its comparison with 2 previous registries. Patients and Methods: Frequency of reperfusion therapy and time intervals between symptom onset – reperfusion therapy were the principal variables investigated. The IAM CAT I (June-December 2000) included 1,450 patients, the IAM CAT II (October 2002-April 2003) 1,386, and the IAM CAT III (October-December 2006) 367. Results: The proportion of patients treated with reperfusion increased progressively (72%, 79% and 81%) as the use of primary angioplasty (5%, 10% and 33%). In the III registry the transfer system most frequently used was the SEM/061 (17%, 32% and 47%, respectively) but the time interval symptom onset-first contact with the medical system did not improve (II, 90 vs III, 105min), the interval symptom onset–thrombolytic therapy did hardly change (178, 165 and 177min) and the interval hospital arrival-trombolysis (needle-door) tended to improve (59, 42 and 42min). Thirty day mortality in STEMI patients declined progressively through the 3 registries (12.1, 10.6 and 7.4%, p=0.012). Conclusions: The proportion of STEMI patients treated with reperfusion has improved but the interval to its application has not been shortened. To improve the latter it is mandatory an earlier contact with the medical system, a shortening of the intervals door-needle and door-balloon through better coordination between the 061, the sanitary personnel and the hospital administration, and to consider the subject as a real sanitary priority (AU)

Costes de la medicina: problemas éticos / The cost of medicine: ethical problems

No disponible