ABSTRACT
OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico. SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.
Subject(s)
Intensive Care Units , Quality of Life , APACHE , Adolescent , Adult , Hospital Mortality , Humans , Prospective StudiesABSTRACT
OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.
ABSTRACT
Objetivo: Se describen con cierta frecuencia pacientes infectados por VIH, que desarrollan neumotórax. Esta complicación aparece fundamentalmente en el contexto de coinfección por Pneumocystis carinii (NPC), pero también asociada a profilaxis con pentamidina inhalada, coinfección por otros gérmenes y a maniobras traumáticas.Método: Revisamos los aspectos más importantes de los neumotórax objetivados en nuestra población infectada por VIH a lo largo de ocho años, antes del inicio de terapia HAART generalizada.Durante este tiempo 97 pacientes fueron diagnosticados de NPC de certeza o probable y 148 pacientes fueron sometidos a profilaxis con pentamidina inhalada mensual. Hemos recogido sólo 14 episodios de neumotórax en 13 pacientes. En diez ocasiones estuvieron en relación a maniobras agresivas, en tres a infección pulmonar concomitante, no estando en relación a patología pulmonar concreta en uno.En cuanto a las maniobras agresivas consistieron en: cateterización de vena subclavia en seis (uno de estos tenía NPC de certeza y otro neumonía por neumococo), en un paciente tras biopsia transbronquial (también con NPC de certeza), en dos agresiones con arma blanca y en el último post-PAAF de adenopatía axilar.Resultados: Las tres infecciones pulmonares concomitantes consistieron respectivamente en tres enfermos en: NPC de certeza (siendo este el único caso con antecedente de profilaxis con pentamidina inhalada), tuberculosis pulmonar activa e infección pulmonar por Pseudomonas a.Todos los pacientes, menos uno, fueron sometidos a drenaje pleural.Nueve se resolvieron tras aspiración. Dos de los tres pacientes con infección pulmonar concomitante, así como el espontáneo, necesitaron pleurodesis, siendo necesaria resección quirúrgica para la resolución del neumotórax asociado a tuberculosis. En el momento de concluir esta revisión habían fallecido seis pacientes (media 7 meses) entre los cuales estaban los tres con NPC de certeza en el momento del neumotórax, el intervenido por tuberculosis y el afecto de infección por Pseudomonas a, presentando todos ellos cifras de CD4 < 100 en el momento del neumotórax, cifra que sólo se apreció en dos de los siete restantes.Conclusiones: El neumotórax es frecuente en pacientes infectados por VIH con coinfección por NPC, pero puede verse durante otras coinfecciones y sobre todo por maniobras agresivas. El neumotórax supone un dato de mal pronóstico en la infección por VIH (AU)
Subject(s)
Adult , Male , Female , Humans , HIV Infections , PneumothoraxABSTRACT
OBJECTIVE: Patients with HIV who develop pneumothorax have been previously described. Pneumocystis carinii pneumonia (PCN) is the leading cause of this complication, but infection by other pulmonary microorganism, inhaled pentamidine therapy and lung invasive manoeuvres have also been associated with pneumothorax in HIV infected patients. METHOD: We review the most relevant clinical aspects of pneumothorax in HIV-infected persons, gathered in our hospital along eight years, before HAART therapy was started. During this time, 97 patients with PCN were diagnosed and 148 patients received prophylaxis with inhaled pentamidine. Only 14 episodes of pneumothorax in 13 patients, were recorded. In ten occasions pneumothorax was related to pulmonary invasive manoeuvres, pulmonary infections were found in three and was considered spontaneous in one. The pulmonary invasive manoeuvres were: subclavia vein catheterisation in six cases (one of them was diagnosed of proved PCN and the other has pneumococcal pneumonia); transbronchial biopsy in one patient (also with proved PCN), knife chest trauma in two cases and after fine needle aspiration of an axillary lymph node in one patient. RESULTS: The pulmonary infections associated with pneumothorax in three patients were: proved PCN (this patient was the only one in the group with inhaled pentamidine prophylaxis who developed pneumothorax), active pulmonary infection by mycobacterium tuberculosis and Pseudomonas aeruginosa pneumonia. A drainage chest tube was placed in 12 patients with complete resolution in nine. In the other two patients pleurodesis was necessary and surgical repair was carried out in the other one (who had pulmonary tuberculosis). During the follow up six patients died (median time to death: 7 months). Among patients who died, five had pulmonary infections when the pneumothorax was diagnosed: PCN in three cases, pulmonary tuberculosis and pseudomonas pneumonia in the other two; all of them with less than 100 CD4 lymphocytes. CONCLUSIONS: Pneumothorax is frequent in HIV-infected patients with PCN, but other lung infections and, above all pulmonary invasive manoeuvres, can cause this complication. In our experience, HIV-infected patients who develop pneumothorax have a bad prognosis.
