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Clinical simulation in Intensive Care Medicine is a crucial tool to strengthen patient safety. It focuses on the complexity of the Intensive Care Unit, where challenging clinical situations require rapid decision making and the use of invasive techniques that can increase the risk of errors and compromise safety. Clinical simulation, by mimicking clinical contexts, is presented as essential for developing technical and non-technical skills and enhancing teamwork in a safe environment, without harm to the patient. in situ simulation is a valuable approach to practice in realistic environments and to address latent security threats. Other simulation methods as virtual reality and tele-simulation are gaining more and more acceptance. Herein, we provide current data on the clinical utility of clinical simulation related to improved safety in the practice of techniques and procedures, as well as improvements of teamwork performance and outcomes. Finally, we propose the needs for future research.
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El primer Programa de Mentoría de SEMICYUC tiene como objetivo apoyar la carrera investigadora de los miembros más jóvenes de la Sociedad. Como beneficios añadidos está la adquisición de nuevas capacidades de investigación y/o clínicas, incrementar la capacidad de reflexión y fomentar el desarrollo de la próxima generación de líderes en la investigación. Este proyecto no sería posible sin el equipo excepcional de mentores o expertos investigadores dispuestos a emprender el viaje con los jóvenes aprendices. El presente artículo expone las bases de dicho programa, además de proponer futuros cambios en haz de una mejora continua (AU)
SEMICYUC's first Mentoring Programme aims to support the research careers of the Society's youngest members. Added benefits include acquiring new research and/or clinical skills, increasing the ability of critical thought, and fostering the development of the next generation of research leaders. This project would not be possible without the exceptional team of mentors or research experts willing to embark on the journey with the young trainees. This article sets out the foundations of such a programme and proposes future changes for continuous improvement (AU)
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Humanos , Mentores , Orientación Vocacional , Investigación , InvestigadoresRESUMEN
SEMICYUC's first Mentoring Programme aims to support the research careers of the Society's youngest members. Added benefits include acquiring new research and/or clinical skills, increasing the ability of critical thought, and fostering the development of the next generation of research leaders. This project would not be possible without the exceptional team of mentors or research experts willing to embark on the journey with the young trainees. This article sets out the foundations of such a programme and proposes future changes for continuous improvement.
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Tutoría , Mentores , HumanosRESUMEN
INTRODUCTION: Critical COVID-19 survivors have a high risk of respiratory sequelae. Therefore, we aimed to identify key factors associated with altered lung function and CT scan abnormalities at a follow-up visit in a cohort of critical COVID-19 survivors. METHODS: Multicenter ambispective observational study in 52 Spanish intensive care units. Up to 1327 PCR-confirmed critical COVID-19 patients had sociodemographic, anthropometric, comorbidity and lifestyle characteristics collected at hospital admission; clinical and biological parameters throughout hospital stay; and, lung function and CT scan at a follow-up visit. RESULTS: The median [p25-p75] time from discharge to follow-up was 3.57 [2.77-4.92] months. Median age was 60 [53-67] years, 27.8% women. The mean (SD) percentage of predicted diffusing lung capacity for carbon monoxide (DLCO) at follow-up was 72.02 (18.33)% predicted, with 66% of patients having DLCO<80% and 24% having DLCO<60%. CT scan showed persistent pulmonary infiltrates, fibrotic lesions, and emphysema in 33%, 25% and 6% of patients, respectively. Key variables associated with DLCO<60% were chronic lung disease (CLD) (OR: 1.86 (1.18-2.92)), duration of invasive mechanical ventilation (IMV) (OR: 1.56 (1.37-1.77)), age (OR [per-1-SD] (95%CI): 1.39 (1.18-1.63)), urea (OR: 1.16 (0.97-1.39)) and estimated glomerular filtration rate at ICU admission (OR: 0.88 (0.73-1.06)). Bacterial pneumonia (1.62 (1.11-2.35)) and duration of ventilation (NIMV (1.23 (1.06-1.42), IMV (1.21 (1.01-1.45)) and prone positioning (1.17 (0.98-1.39)) were associated with fibrotic lesions. CONCLUSION: Age and CLD, reflecting patients' baseline vulnerability, and markers of COVID-19 severity, such as duration of IMV and renal failure, were key factors associated with impaired DLCO and CT abnormalities.
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COVID-19 , Enfisema Pulmonar , Humanos , Femenino , Persona de Mediana Edad , Masculino , Enfermedad Crítica , Estudios de Seguimiento , COVID-19/complicaciones , Progresión de la Enfermedad , Pulmón/diagnóstico por imagenRESUMEN
BACKGROUND: Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce. METHODS: A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research. RESULTS: We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers. CONCLUSIONS: In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.
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Deterioro Clínico , Equipo Hospitalario de Respuesta Rápida , Estudios Transversales , Humanos , Unidades de Cuidados Intensivos , Mejoramiento de la CalidadRESUMEN
INTRODUCTION: The information about the pharmacokinetics and optimal dose of tigecycline in critically ill patients with severe underlying diseases is limited and controversial. In this study, we evaluate the pharmacokinetic parameters of tigecycline in critically ill patients with multidrug-resistant Gram-negative infection and explore the association between the pharmacokinetic/pharmacodynamic ratio and treatment response. METHODS: A prospective study was designed including critically ill patients treated with tigecycline for multidrug-resistant Gram-negative infections. Blood samples were collected at day 3-5 of treatment, and pharmacokinetics parameters were evaluated using NONMEM® software. Relationship between area under the free concentration-time curve and minimum inhibitory concentration ratio (fAUC/MIC) and treatment failure was evaluated. Association between tigecycline fAUC and hepatobiliary toxicity was also investigated. RESULTS: Twenty-five critically ill patients were included in the study. In the pharmacokinetic model, weight and total bilirubin level were found to be significant predictors of tigecycline clearance. Fifteen (60.0%) patients achieved an fAUC/MIC ratio >4.5, seven (28.0%) an fAUC/MIC > 6.96 and only three (12.0%) an fAUC/MIC > 17.9. No differences in fAUC/MIC ratio were obtained between those patients with and without clinical failure (5.28 (IC95%: 2.57-7.94) vs 8.71 (3.57-13.84)). fAUC values were higher in those patients who suffered hepatobiliary disorders (7.63 (3.93-11.34) vs 17.63 (7.85-26.28) mg/L/h). CONCLUSION: An important percentage of critically ill patients with multidrug-resistant Gram-negative infection treated with tigecycline do not achieve an appropriate pharmacokinetic/pharmacodynamic value. Tigecycline fAUC seems to be associated with hepatobiliary disorders in this study population. The effect of fAUC/MIC ratio on clinical response remains unclear.
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Objectives: To assess tolvaptan's efficacy and safety in critical care patients with volume overload. Methods: Prospective observational study. Twenty-eight patients in the recovery phase from multiple organ failure and with volume overload refractory to conventional therapy treated with tolvaptan were included. Results: Patients received an initial daily dose of 3.75 (n=1), 7.5 (n=8) and 15 (n=19) mg of tolvaptan. Median treatment duration was 2 days (range: 1 to 12). All patients presented an increase in 24 hours diuresis after the first dose (median increase from baseline (IQR)=1114 (285-1943) mL), with a median net daily fluid loss of 1007 mL (456-2380) mL after 24 hours. High diuretic efficacy (daily fluid loss higher than 0.5 L with tolvaptan first dose) was detected in 18 patients (64.3%). Initial hyponatraemia was present in 16 (57.1%) patients, while overly rapid correction with tolvaptan treatment occurred in two patients without clinical consequences. Two patients presented hypophosphataemia after treatment. Conclusion: Tolvaptan is an effective therapeutic option in critically ill patients with volume overload refractory to conventional diuretics. Further studies are required to evaluate its safety profile and its effect on short-term outcomes and mortality.
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Antagonistas de los Receptores de Hormonas Antidiuréticas/administración & dosificación , Enfermedad Crítica , Tolvaptán/administración & dosificación , Desequilibrio Hidroelectrolítico/tratamiento farmacológico , Antagonistas de los Receptores de Hormonas Antidiuréticas/efectos adversos , Diuresis/efectos de los fármacos , Diuréticos/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tolvaptán/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVES: To assess the probability of reaching adequate pharmacokinetic/pharmacodynamics values for ceftolozane/tazobactam at different doses and degrees of renal functions in patients with Pseudomonas aeruginosa bacteremia. METHODS: Six dosing regimens were evaluated: 0.5/0.25 g, 1/0.5 g, and 2/1 g every 8 hours given as 1 hour or 3 hours infusions. Pharmacokinetic data were obtained from the literature. Susceptibility data to ceftolozane were collected from patients with P aeruginosa infection treated with ceftolozane-tazobactam. Probability of reaching a fraction of time (fT) >40% minimum inhibitory concentration (MIC) and fT >100%MIC value for ceftolozane at 3 different renal clearance values was evaluated. For tazobactam, the probability of reaching an fT >40% and >70% for 3 limit values was calculated. RESULTS: Thirty-seven strains were included. For ceftolozane, the probability of reaching a fT >40%MIC was greater than 90% for any degree of renal function. The probability of reaching a fT >100%MIC for 1 g dose infused over 1 hour and 3 hours was 82.2% and 86.4% for a creatinine clearance (ClCr) >90 mL/min. Using a 2 g dose, the probability was greater than 90% for both infusions rates. For tazobactam, the probability of reaching a value of fT >50% of the limit concentrations was greater than 90% for a ClCr of 70 mL/min. In the case of a ClCr >90 mL/min and limit concentration values ≥ 0.25 mg/mL, only extended infusions showed a probability >90%. CONCLUSIONS AND RELEVANCE: The standard doses of ceftolozane/tazobactam achieve an adequate fT >40%MIC value. However, doses of 2 g in extended infusion is necessary to reach a value of fT >100%MIC, especially in patients with an increased renal clearance and high levels of beta-lactamases expression.
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Effective treatment approaches for biofilms in endotracheal tubes (ETTs) are lacking. In this study, we evaluated the in vitro effects of five antimicrobials against biofilms formed by Klebsiella pneumoniae in ETTs. K. pneumoniae was added to minimal mucin medium prior to inoculation in microtiter plates containing ETT fragments. Biofilm susceptibility was assessed by crystal violet staining. At 24 h, the antimicrobials significantly reduced biofilm formation. At 48 h, all of the antimicrobial agents exhibited significant reductions in biofilm formation, even at concentrations above the minimum inhibitory concentration (MIC). Tigecycline and fosfomycin showed the greatest inhibition capacity, with good activity at concentrations twofold greater than the MIC. K. pneumoniae exhibited excellent biofilm formation ability, with formation in the first 24 h and significantly reduced antimicrobial activity. These results contribute to the establishment of new antibiotic breakpoints for the adequate management of infections associated with biofilm formation. Abbreviations ETT Endotracheal tube MIC Minimum inhibitory concentration MBIC Minimum biofilm inhibitory concentration OD Optical density PBS Phosphate-buffered saline VAP Ventilator-associated pneumonia.
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Antiinfecciosos/farmacología , Biopelículas/efectos de los fármacos , Intubación Intratraqueal/efectos adversos , Infecciones por Klebsiella/tratamiento farmacológico , Klebsiella pneumoniae/efectos de los fármacos , Humanos , Infecciones por Klebsiella/microbiología , Pruebas de Sensibilidad Microbiana/métodos , Neumonía Asociada al Ventilador/tratamiento farmacológico , Neumonía Asociada al Ventilador/microbiologíaRESUMEN
WHAT IS KNOWN AND OBJECTIVE: Several authors have demonstrated the relationship between voriconazole concentrations and the risk of therapeutic failure and adverse events However, the information about voriconazole concentrations in the critically ill patient is scarce. The aim of this study was to analyse the plasma concentrations and pharmacokinetic behaviour of voriconazole in critically ill patients and their association with the treatment response and development of toxicity. METHODS: A prospective, observational study was conducted. Patients admitted to an intensive care unit and on treatment with intravenous voriconazole were included. Plasma concentrations were measured between days 4 and 7 from the start of the treatment. The pharmacokinetic analysis was performed using the NONMEM® software. A regression model was used to evaluate the variables associated with the values outside the therapeutic range, as well as the relationship between the plasma concentrations and the treatment response and the development of hepatotoxicity. RESULTS AND DISCUSSION: A total of 33 patients were included. Plasma concentrations outside the therapeutic range (1-5.5 mg/L) were observed in 15 patients, being above the established range in 9 (27.3%) cases, and below it in 6 (18.2%) cases. The presence of a bilirubin value of >1.5 mg/dL and a C-reactive protein >100 mg/dL was associated with supra-therapeutic concentrations. Voriconazole concentrations greater than 5.5 mg/dL were associated with the development of hepatotoxicity. WHAT IS NEW AND CONCLUSIONS: There is a wide variation in voriconazole concentrations in critically ill patients, being associated with a high frequency of adverse events. Close monitoring of these values is required in order to decrease the risk of therapeutic failure and toxicity.
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Antifúngicos/sangre , Antifúngicos/farmacocinética , Voriconazol/sangre , Voriconazol/farmacocinética , Bilirrubina/metabolismo , Enfermedad Crítica , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Plasma/metabolismo , Estudios ProspectivosRESUMEN
OBJECTIVES: The aim of this study was to determine the persistence of the adverse prognostic effect of elevated vancomycin minimum inhibitory concentration (MIC) in methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in a setting with low vancomycin use. METHODS: A retrospective study focusing on episodes of bacteraemia due to MRSA diagnosed from January 2010 through December 2015 was designed. The main outcome measures were 30-day mortality and treatment failure. Multivariate logistic regression analysis was used to identify variables associated with patient mortality and treatment outcome. RESULTS: In total, 79 MRSA bacteraemia episodes were included. The vancomycin MIC was >1.0µg/mL in 53 episodes (67.1%). The presence of high vancomycin MIC was not associated with a higher mortality rate or treatment success. A daptomycin MIC≥0.5µg/mL was present in 16 (26.2%) of 61 episodes for which the daptomycin MIC was obtained and was associated with 30-day mortality in the multivariate analysis (odds ratio=4.72, 95% confidence interval 1.19-18.71). None of the antimicrobials used were associated with a lower risk of treatment failure or mortality. CONCLUSIONS: The pernicious effect of high vancomycin MIC disappears in the absence of a predominant use of this antibiotic. However, a high daptomycin MIC in MRSA bacteraemia is associated with higher mortality in patients with bacteraemia, irrespective of antimicrobial treatment choice.
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Antibacterianos/farmacología , Bacteriemia/tratamiento farmacológico , Daptomicina/farmacología , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Infecciones Estafilocócicas/tratamiento farmacológico , Vancomicina/farmacología , Anciano , Bacteriemia/mortalidad , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Retrospectivos , España , Infecciones Estafilocócicas/microbiología , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
OBJECTIVES: This study evaluated the association between the pharmacokinetic/pharmacodynamic index and treatment response to amikacin in critically ill patients. METHODS: An observational prospective study was designed. Critically ill adult patients with infection due to amikacin-sensitive Gram-negative bacteria treated with amikacin were included. Amikacin maximum (Cmax) and minimum (Cmin) plasma concentration samples were taken during the first 48-96h after the beginning of treatment. The impact of Cmax/MIC ratio and area under the concentration-time curve (AUC)/MIC ratio on early and final clinical response, microbiological eradication, development of resistant strains and renal toxicity was analysed using a multivariate model. RESULTS: A total of 85 patients received amikacin treatment, of whom 71 (83.5%) achieved a Cmax/MIC >6, 66 (77.6%) a Cmax/MIC >8, 64 (75.3%) a Cmax/MIC >10 and 72 (84.7%) an AUC/MIC >65. Clinical response at the end of treatment was significantly greater in patients with Cmax/MIC >6 [OR=5.48 (95% CI 1.28-11.40)], Cmax/MIC >8 [OR=6.01 (2.41-12.2)] and Cmax/MIC >10 [OR=8.02 (2.21-14.2)]. Cmax/MIC >10 was associated with a non-significant increase in microbiological eradication [OR=2.84 (0.76-10.61)]. Achieving Cmax/MIC >6 was associated with a lower proportion of patients with selection of resistant strains or with an increase in amikacin MIC (27.8% vs. 10.2%). Amikacin AUC was associated with development of nephrotoxicity [ROC curve 0.77 (0.66-0.87)]. CONCLUSIONS: The Cmax/MIC ratio of amikacin in critically ill patients is directly related to the response to treatment and the selection of resistant strains.
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Amicacina/farmacocinética , Antibacterianos/farmacocinética , Enfermedad Crítica/terapia , Anciano , Anciano de 80 o más Años , Amicacina/efectos adversos , Amicacina/economía , Amicacina/uso terapéutico , Antibacterianos/efectos adversos , Antibacterianos/economía , Antibacterianos/uso terapéutico , Enfermedad Crítica/economía , Economía Farmacéutica , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
In this study, we evaluate the effect of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (Levitronix) on the pharmacokinetic of amikacin in critically ill patients. Twelve patients with ECMO and three with Levitronix devices who started treatment with amikacin were included. Amikacin pre (Cmax) and post (Cmin) dose serum concentrations were measured during the first 72-96 hours of treatment initiation. Pharmacokinetic parameters were performed by Bayesian adjustment. The median initial dose was 1,000 mg (range: 600-1,400 mg). Mean plasma concentrations were Cmax 58.6 mg/L (17.0 mg/L); Cmin 9.58 mg/L (7.8 mg/L). Patients with an ECMO device had a higher volume of distribution (0.346 [0.033] vs. 0.288 [0.110] L/kg) and a lower plasma clearance (1.58 [0.21] vs. 3.73 [1.03] L/h) than the control group. This phenomenon was also observed in those patients with simultaneous use of ECMO and hemodilafiltration. For patients with Levitronix system, no significant alterations in the volume of distribution were observed, although a lower plasma clearance was noticed. Placement of ECMO devices alters the pharmacokinetic parameters of amikacin in the critically ill patients and should be considered when selecting the initial dose.
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Amicacina/farmacocinética , Antibacterianos/farmacocinética , Oxigenación por Membrana Extracorpórea , Corazón Auxiliar , Infecciones Relacionadas con Prótesis/prevención & control , Teorema de Bayes , Cuidados Críticos , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Corazón Auxiliar/efectos adversos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: To analyse the effect of haemodiafiltration (CVVHDF) flow rate on amikacin pharmacokinetics and blood concentrations. METHODS: Prospective observational study. Patients receiving CVVHDF and amikacin treatment were included. Pharmacokinetic parameters were calculated using Bayesian analysis. Spearman correlation test was used in order to assess the influence of CVVHDF flux on amikacin minimum concentration (Cmin) and plasma clearance. RESULTS: Thirty patients undergoing CVVHDF procedures were included. The treatment with amikacin started at an initial mean dose of 12.4 (4.1) mg/kg/day. An association between the flow rate and Cmin value (r = 0.261; p = 0.161) and plasma clearance was found (r = 0.268; p = 0.152). Four patients (13.3%) were not able to achieve peak concentration over MIC value higher than 8. In 4 patients, amikacin had to be discontinued due to a high Cmin value. CONCLUSIONS: Amikacin clearance in patients with CVVHDF is affected by the flow rate used. Therefore, CVVHDF dose should be taken into account when dosing amikacin.
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Amicacina/administración & dosificación , Amicacina/farmacocinética , Hemodiafiltración , Anciano , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Continuous renal replacement therapy (CRRT) is common practice in critical care patients with acute renal failure. OBJECTIVES: To evaluate the adequacy of antimicrobial doses calculated based on the total drug clearance and dose recommended by different guides in critically ill patients undergoing CRRT. METHODS: Retrospective observational study. Patients admitted to a critical care unit during May 2014 to May 2016 and subjected to CRRT were included. The recommended dose was established as the product of the usual dose of the drug by total drug clearance. RESULTS: 177 antimicrobial agents, used in 64 patients were analysed; 45 (25.4%) antimicrobials were given in an insufficient dose (<20%) according to the theoretical calculation. Following the recommendations in the revised guidelines, between 10% and 20% of antimicrobials were given in insufficient doses. A higher success rate of treatment in those patients not receiving a low drug dosage was seen (35.2% vs 24.0%). CONCLUSIONS: There is a great disparity between the antimicrobial dose prescribed, recommended and calculated based on drug clearance in critically ill patients undergoing CRRT.
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BACKGROUND: Health-care associated infections are a major cause of morbidity and mortality in critical care units. The aim of this study is to evaluate the effectiveness of chlorhexidine gluconate (CHG)-impregnated wipes in the daily bathing of patients in an intensive care unit (ICU) to prevent cross-transmission and colonization by multidrug-resistant organisms (MDROs) METHODS: Prospective cohort study with an intervention of 11 months. The intervention consisted of using CHG-impregnated wipes for the daily bathing of patients on mechanical ventilation or colonized by MDROs. Monthly trends in the number of patients colonized by MDROs and the incidence of nosocomial infections were evaluated. RESULTS: A total of 1,675 patients were admitted to the unit during the intervention period, and 430 (25.7%) were bathed with chlorhexidine wipes. A significant decrease was observed in the incidence of colonization by MDROs over the months (ß = -0.209; r2 = 0.549; P = .027), and in the number of patients colonized compared with the equivalent period of the previous year (22.0% vs 18.4%; P = .01). No significant decrease was observed in the incidence of nosocomial infection between the two periods (4.11% vs 4.57%; P = .355). No dermatologic problems were observed in the treated patients. CONCLUSIONS: The use of CHG-impregnated wipes reduces cross-transmission and colonization by MDROs in the ICUs in an endemic situation because of multidrug-resistant Enterobacteriaceae.
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Baños/métodos , Clorhexidina/administración & dosificación , Infección Hospitalaria/prevención & control , Transmisión de Enfermedad Infecciosa/prevención & control , Desinfectantes/administración & dosificación , Farmacorresistencia Bacteriana Múltiple , Control de Infecciones/métodos , Adulto , Anciano , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Infecciones por Enterobacteriaceae/epidemiología , Infecciones por Enterobacteriaceae/microbiología , Infecciones por Enterobacteriaceae/prevención & control , Femenino , Humanos , Incidencia , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: To compare the utility of a multiplex polymerase chain reaction system (SeptiFast) and blood cultures for detecting bacteria and fungi in blood samples from patients with severe sepsis or septic shock. METHODS: In a prospective observational study, whole blood samples for SeptiFast testing and for culture were collected on admission from all patients with severe sepsis or septic shock admitted to the intensive care unit between July 2011 and September 2012. SeptiFast results were compared with blood and other culture results. RESULTS: The probability of at least 1 microorganism being isolated at 6 hours was 13-fold higher with the SeptiFast test than with blood cultures (relative risk, 13.5; 95% CI, 5.05-36.06). Unlike culture results, SeptiFast test results were not associated with previous antibiotic consumption. The median time to the first positive blood culture result was 17 hours; SeptiFast results were available in 6 hours. SeptiFast detected genetic material from potentially multiresistant microorganisms in patients whose blood cultures showed no growth at all. CONCLUSIONS: The SeptiFast test provided quicker microbiological diagnosis and identified significantly more microorganisms than blood cultures did, particularly when samples were collected after antibiotic therapy had started or infections were due to resistant bacteria and yeast.
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Bacterias/aislamiento & purificación , ADN Bacteriano/sangre , ADN de Hongos/sangre , Hongos/aislamiento & purificación , Reacción en Cadena de la Polimerasa Multiplex , Sepsis/diagnóstico , Anciano , Bacteriemia/sangre , Bacteriemia/diagnóstico , Bacteriemia/microbiología , Bacterias/genética , Coinfección/sangre , Coinfección/diagnóstico , Coinfección/microbiología , Diagnóstico Precoz , Reacciones Falso Negativas , Femenino , Fungemia/sangre , Fungemia/diagnóstico , Fungemia/microbiología , Hongos/genética , Humanos , Unidades de Cuidados Intensivos , Masculino , Técnicas Microbiológicas , Persona de Mediana Edad , Estudios Prospectivos , Sepsis/sangre , Sepsis/microbiología , Choque Séptico/sangre , Choque Séptico/diagnóstico , Choque Séptico/microbiología , Factores de TiempoRESUMEN
PRINCIPLES: Midregional proadrenomedullin (proADM) is a novel biomarker with potential prognostic utility in patients with community-acquired pneumonia. The aim of this study was to investigate the value of proADM levels for severity assessment and outcome prediction in severe sepsis and septic shock due to CAP. METHODS: Prospective observational study including 49 patients admitted to ICU with both a clinical and radiologic diagnosis of pneumonia and fulfilling criteria for severe sepsis or septic shock. The prognostic accuracy of proADM levels was compared with those of pneumonia severity index and of procalcitonin (PCT) and C-reactive protein (CRP). RESULTS: 49 patients with severe sepsis or septic shock due to CAP were included in the study. Mortality was 24.5% for ICU and 34.7% for hospital mortality. In all cases proADM values at ICU admission were pathological (considering normal proADM levels <4 nmol/L). ProADM consistently rose as PSI class advanced from II to V (p = 0.02). Median proADM levels were higher (p <0.01) in hospital non-survivors 5.0 (1.9-10.1) nmol/L vs. survivors 1.7 (1.3-3.1) nmol/L. These differences were also significant with respect to ICU mortality. The receiver-operating characteristic curve for proADM yielded an AUC of 0.72; better than the AUC for PCT and CRP (0.40 and 0.44 respectively) and similar to PSI (0.74). CONCLUSIONS: In our study MR-proADM levels correlate with increasing severity of illness and death. High MR-proADM levels offer additional risk stratification in high-risk CAP patients.
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Adrenomedulina/sangre , Infecciones Comunitarias Adquiridas/sangre , Neumonía Bacteriana/sangre , Precursores de Proteínas/sangre , Choque Séptico/sangre , Biomarcadores/sangre , Infecciones Comunitarias Adquiridas/complicaciones , Infecciones Comunitarias Adquiridas/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Inmunoensayo , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/complicaciones , Neumonía Bacteriana/diagnóstico , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Choque Séptico/diagnóstico , Choque Séptico/etiologíaRESUMEN
Early compliance with the sepsis resuscitation bundle has been suggested to reduce mortality. However, few data are available about the impact of late compliance with the bundle on outcomes. The aim of this study was to assess whether the completion of the resuscitation bundle within the first 6 h after admission to the intensive care unit (ICU), but beyond the specific time limit of the various bundle interventions, is related to an improvement in survival. This prospective, cohort study included 753 patients recruited from September 2005 until August 2010 with severe sepsis/septic shock in the three medical-surgical ICUs of a tertiary academic medical center. We assessed the compliance with the different tasks included in the resuscitation bundle. Furthermore, we ascertained within the first 6 h after ICU admission the compliance with those tasks not carried out within their specific time limits; we have termed this variable "bundle improvement in the ICU." Septic shock was present in 88.1%. The overall in-hospital mortality was 31.6%. In 51.5%, there was bundle improvement in the ICU; this variable was associated with a lower risk of mortality (adjusted hazard ratio, 0.52 [95% confidence interval, 0.34-0.78]). That association was observed only when the time from severe sepsis onset to ICU admission was 6 h or less. Importantly, similar results were found after excluding all patients with severe sepsis (rapid responders) and those with refractory shock (nonresponders). The task with highest improvement was the achievement of central venous oxygen saturation 70% or greater in 39% of patients. Compliance with the resuscitation bundle even beyond the recommended time is associated with improvement in survival in patients with severe sepsis/septic shock.