Membrana de oxigenación extracorpórea (ECMO) y ventilación mecánica ultraprotectora en el estatus asmático casi fatal / Extracorporeal membrane oxygenation (ECMO) and ultraprotective mechanical ventilation for near-fatal status asthmaticus

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Soporte con membrana de oxigenación extracorpórea en paciente con miocardiopatía de estrés secundaria a feocromocitoma / Extracorporeal membrane oxygenation support in a patient with pheochromocytoma stress myocardyopathy

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Enfisema gástrico iatrogénico / Iatrogenic gastric emphysema

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Retroneumoperitoneo por espondilodiscitis fulminante / Retropneumoperitoneum due to fulminant spondylodiscitis

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Postoperative Care in Kidney Transplantation: A Comparison Between Controlled and Uncontrolled Donation After Circulatory Death.

Recent research in kidney transplantation has revealed differences in the evolution of renal function among patients transplanted from 2 alternative programs for donation after circulatory death (DCD). A retrospective, observational, single-center study was carried out from 2013 to 2016 at a level III hospital intensive care unit (ICU) to assess the progression of kidney recipients after transplants from uncontrolled DCD (uDCD) or controlled DCD (cDCD). The following variables were collected for data analysis: demographics, comorbidities, type of donation, lactate, hemoglobin and glucose levels at ICU admission, creatinine concentration at ICU admission, at-hospital ward transfer, at-hospital discharge, radioisotope imaging results, ICU and in-hospital length of stay, and mortality. There were 87 patients eligible for analysis, 42.5% of which were uDCD recipients. Improvement in kidney function was significantly delayed after uDCD compared with cDCD. A multivariate analysis showed that both uDCD and lactate levels at ICU admission increase the risk of poor outcome after renal transplantation. No deaths were registered in either patient group. Our results suggest that kidney transplantation recipients from uDCD recover renal function at a slower rate than patients transplanted from cDCD, a factor that does not affect mortality.

Results of Controlled Donation After Circulatory Death in a Third-Level Hospital.

OBJECTIVE: To investigate the characteristics and evolution of controlled donation after circulatory death (DCD) type III. MATERIALS AND METHODS: Observational and retrospective study of controlled DCD type III of donors conducted from 2014 to 2016. Clinical data, intensive care unit (ICU) stay, cause of death, warm ischemia time, and total time were collected. Delayed graft function (DGF) and survival of renal transplant were also registered. Qualitative variables are described as frequencies and absolute values and quantitative variables as medians and interquartile ranges. RESULTS: A total of 21 donors were collected; 71% (15) were males, median age was 55 years (interquartile range [IR] 48-72), and median ICU stay was 7 days (IR 4-12). The main cause of death was anoxic encephalopathy (57%, 12), followed by intracerebral hemorrhage (28%, 6). In 48%, withdrawal of life support occurred in the operating room, and 98% of donors were preserved by abdominal super-rapid cannulation technique. Average warm ischemia time was 20 minutes (IR 16-24), and total ischemia time was 26 minutes (IR 23-34). Of the donations, 57% were livers and 90% were kidneys. Out of 42 kidneys donated, 54% (23) of them were valid. Median renal transplant hospital stay was 18 days (IR 6-24), and 46% develop DGF. Survival at discharge was 100%. CONCLUSION: DCD type III ensures a source of organs. The main cause of death was anoxic encephalopathy. Most donors were able to donate some solid organ.

Living Donor in Renal Transplantation: Minimizing Risks.

In recent years, the broadening of indications for renal transplantation, together with the progressive reduction of donations following brain stem death, has led to living donation being considered in increasing numbers of cases for renal transplantation. To investigate this further, it is necessary to assess the impact it has on the postoperative outcomes in the intensive care unit (ICU). Our group conducted a retrospective, observational, single-center study from 2013 to 2016 to evaluate differences in outcomes between living and cadaveric kidney donation both during ICU admission and total hospitalization. We compared differences in characteristics between living and deceased graft recipients including demographics, comorbidities, analytical data, radioisotope imaging test results, complications, ICU and hospital ward length of stay, and mortality. In all, 387 patients were eligible for analysis, and 13% received living donor grafts. Our results demonstrate that this group had significantly fewer complications, shorter length of hospital stay, and reduced mortality in comparison with recipients of cadaveric donor grafts. The better postoperative outcomes from living donor grafts could result from careful selection of the donor and less inflammatory injury, minimizing risk in the postoperative period.

Pneumonia in mechanically ventilated patients: no diagnostic and prognostic value of different quantitative tracheal aspirates thresholds.

BACKGROUND: Diagnosis of pneumonia in ventilated patients is challenging due to the lack of specific and definitive clinical symptoms, laboratory data or radiological abnormalities. METHODS: Based on quantitative tracheal aspirate (QTA) results, three groups of patients were compared: <105 cfu/ml, ≥105 cfu/ml and <106 cfu/ml, and ≥106 cfu/ml. We recorded demographic variables, underlying diseases and severity of illness at ICU admission. On the day of pneumonia diagnosis, we registered temperature, leukocyte count, C-reactive protein, Sequential Organ Failure Assessment (SOFA) score, clinical pulmonary infection score (CPIS) and adequacy of empirical antimicrobial therapy. RESULTS: In 231 episodes, clinical presentation, laboratory data, severity of illness, CPIS, the presence of bacteremia and radiological score did not differ among the three groups. ICU and hospital mortalities were also similar in the three groups. Factors independently associated with in-hospital mortality were age, SOFA score and inappropriate antimicrobial therapy. The bacterial burden in the QTA was not included in the model. CONCLUSIONS: Quantification of tracheal aspirate samples may not be necessary in ventilated patients clinically suspected of having nosocomial pneumonia.

Antibiotic resistance: thinking outside the hospital / Resistencia a antibióticos: pensando fuera del hospital

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Mortality of Oncohematological Patients Undergoing Hematopoietic Stem Cell Transplantation Admitted to the Intensive Care Unit.

BACKGROUND: Both autologous and allogenic hematopoietic stem cell transplantation (HSCT) are potentially curative treatments for hematological malignancies. Patients with related complications may need admission to the intensive care unit (ICU) for specific therapy and organ support. A consensus on treatment between hematologists and intensive care specialists is essential. METHODS: This observasional, retrospective study included all recipients of HSCT in a third-level hospital during 2013 and 2014. Certain parameters were taken into account for patients who needed to be admitted to the ICU, evolution, and ICU and hospital mortality. RESULTS: A total of 228 HSCT were carried out: 127 autologous (55.7%) and 101 allogenic (44.3%). Twenty-four patients were admitted to the ICU; 22 had received allogenic HSCT and 2 autologous. The main underlying conditions were acute leukemias (41.6%) and myelodysplastic syndromes (20.8%). Of these patients, 45.8% were in complete remission and 33.3% were in relapse or progression. Causes of admission to the ICU were mainly respiratory failure (70.8%) followed by shock requiring vasoactive drugs. High values for severity scores were observed for APACHE II 25 (19-28) and SOFA 10 (8-14). During hospitalization, a high percentage of patients had hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. Mortality in the ICU was 83.3% and hospitalary, 91.7%. All patients requiring invasive mechanical ventilation died in the ICU. CONCLUSIONS: Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate of >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support.

Hemosuccus pancreaticus. A propósito de un caso / Hemosuccus pancreaticus. A case report

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De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock.

PURPOSES: We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock. METHODS: We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis. RESULTS: A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9%). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95% confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95% CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality. CONCLUSIONS: De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.

Kidney failure after heart transplantation.

BACKGROUND AND PURPOSE: Heart transplantation is a procedure with a high mortality rate. Altered kidney function (AKF) after a heart transplant is common. The purpose of this study was to determine the incidence of and associated factors for renal dysfunction among patients who underwent heart transplantation in our hospital between January 2006 and November 2008. PATIENTS AND METHODS: This retrospective observational study was performed on all patients receiving a heart transplant between January 1, 2006 and November 15, 2008. The following variables were recorded: patient comorbidities, indication, presurgical urea and creatinine levels, donor variables, surgical procedure, and postoperative features. RESULTS: A total of 54 heart transplantations were performed with 68.5% of patients being male. The average age at transplant was 49.52 years (±13.45 y) and the mean weight 72.5 kg (±14.8 kg). Overall mortality was 28.30%. Of the 54 patients, 70.4% showed AKF during the first week after transplantation; 30.61% were in stage III according to the Acute Kidney Injury classification. There were no statistically significant differences between the group of patients with versus without renal failure, except for the extracorporeal surgery time, which was significantly longer among those patients who had AKF, and glycemia, which was also higher in the immediate postoperative period. Analysis of patient mortality showed no significant differences for the patients with AKF (80% vs 68.4%; P=31). CONCLUSIONS: The rate of acute kidney failure was high (70.4%), as was the use of chronic renal replacement therapy (28.85%), but it decreased considerably when followed over time.