[Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units]. / Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital / Update and recommendations in decision making referred to limitation of advanced life support treatment

El Grupo de Trabajo de Bioética de la SEMICYUC ha elaborado las recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital con la aspiración de disminuir la variabilidad en la práctica clínica observada y de contribuir a la mejora de los cuidados al final de la vida del paciente crítico. Además de abordar el marco conceptual de la limitación de tratamientos de soporte vital y de la futilidad, desarrolla las nuevas formas de limitación extendiéndola a la adecuación de otros tratamientos y métodos diagnósticos, además de planificar los posibles cursos evolutivos tras la decisión de limitación de tratamientos de soporte vital. Se enfatiza la importancia de la planificación compartida de la asistencia sanitaria en la toma de decisiones, se presentan los cuidados intensivos orientados a la donación y se promueve la integración de los cuidados paliativos en el tratamiento del paciente crítico en estadios del final de la vida en UCI

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit

Update and recommendations in decision making referred to limitation of advanced life support treatment. / Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Encuesta nacional sobre los indicadores de calidad en Bioética de la SEMICYUC, en los servicios de Medicina Intensiva en España / National survey on the indicators of quality in Bioethics of the SEMICYUC in the departments of Intensive Care Medicine in Spain

Introducción: En los servicios de Medicina Intensiva (SMI) se realizan múltiples intervenciones a los pacientes críticos. Nuestros objetivos son conocer la presencia en la práctica diaria de los SMI de elementos relacionados con los 6 indicadores de calidad en Bioética de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias y la participación de sus miembros en los comités de ética asistencial. Material y métodos: Estudio observacional multicéntrico mediante encuesta que estudia aspectos descriptivos de los SMI, plantea 25 cuestiones relacionadas con los indicadores de calidad bioéticos y describe la participación de miembros del SMI en los comités de ética asistencial. Los SMI se clasifican por tamaño (mayor/menor de 10 camas) y tipo de hospital (público/privado-concertado, docente/no docente). Resultados: En las 68 encuestas analizadas encontramos: información familiar diaria (97%), efectuada en sala de información (82%); protocolos de cuidados al final de vida (44%); formulario de limitación de tratamiento de soporte vital (48,43%); protocolo de contención (40%). El cumplimiento del proceso de consentimiento informado es: traqueostomía (92%), intervención vascular (76%), depuración extrarrenal (25%). La presencia actual de miembros del SMI en el Comité de Ética es frecuente (69%). Conclusiones: La información a familiares es adecuada, aunque hay SMI sin sala de información. El cumplimiento del proceso de consentimiento informado de varios procedimientos es insuficiente. La participación de miembros del SMI en los comités de ética asistencial es frecuente. Los resultados evidencian margen de mejora en la calidad bioética de los SMI (AU)

Introduction: Multiple interventions are performed in critical patients admitted to Intensive Care Units (ICUs). This study explores the presence in the daily practice of ICUs of elements related to the 6 bioethics quality indicators of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, and the participation of their members in the hospital ethics committees. Materials and methods: A multicenter observational study was carried out, using a survey exploring descriptive aspects of the ICUs, with 25 questions related to bioethics quality indicators, and assessing the participation of ICU members in the hospital ethics committees. The ICUs were classified by size (larger or smaller than 10 beds) and type of hospital (public/private-public concerted center, with/without teaching). Results: The 68 analyzed surveys revealed: daily informing of the family (97%), carried out in the information room (82%); end-of-life care protocols (44%); life support limitation form (48.43%); and physical containment protocol (40%). Compliance with the informed consent process referred to different procedures is: tracheostomy (92%), vascular procedures (76%), and extrarenal clearance (25%). The presence of ICU members in the hospital ethics committee is currently frequent (69%). Conclusions: Information supplied to relatives is adequate, although there are ICUs without an information room. Compliance with the informed consent requirements of various procedures is insufficient. The participation of ICU members in the hospital ethics committees is frequent. The results obtained suggest a chance for improvement in the bioethical quality of the ICU (AU)

National survey on the indicators of quality in Bioethics of the SEMICYUC in the departments of Intensive Care Medicine in Spain. / Encuesta nacional sobre los indicadores de calidad en Bioética de la SEMICYUC, en los servicios de Medicina Intensiva en España.

INTRODUCTION: Multiple interventions are performed in critical patients admitted to Intensive Care Units (ICUs). This study explores the presence in the daily practice of ICUs of elements related to the 6 bioethics quality indicators of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, and the participation of their members in the hospital ethics committees. MATERIALS AND METHODS: A multicenter observational study was carried out, using a survey exploring descriptive aspects of the ICUs, with 25 questions related to bioethics quality indicators, and assessing the participation of ICU members in the hospital ethics committees. The ICUs were classified by size (larger or smaller than 10 beds) and type of hospital (public/private-public concerted center, with/without teaching). RESULTS: The 68 analyzed surveys revealed: daily informing of the family (97%), carried out in the information room (82%); end-of-life care protocols (44%); life support limitation form (48.43%); and physical containment protocol (40%). Compliance with the informed consent process referred to different procedures is: tracheostomy (92%), vascular procedures (76%), and extrarenal clearance (25%). The presence of ICU members in the hospital ethics committee is currently frequent (69%). CONCLUSIONS: Information supplied to relatives is adequate, although there are ICUs without an information room. Compliance with the informed consent requirements of various procedures is insufficient. The participation of ICU members in the hospital ethics committees is frequent. The results obtained suggest a chance for improvement in the bioethical quality of the ICU.

SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis.

OBJECTIVE: Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS: Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS: Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.

[Clinical pathways in acute pancreatitis: recommendations for early multidisciplinary management. Scientific Committee of the SEMICYUC. Working Group on Infectious Diseases (GTEI-SEMICYUC)]. / Hoja de ruta de los cuidados clínicos para la pancreatitis aguda: recomendaciones para el manejo anticipado multidisciplinar (clinical pathways).

There is a growing body of evidence that early management of patients with acute pancreatitis may alter the natural course of disease and improve outcomes of patients. The aim of this paper is to optimize the management of patients with acute pancreatitis during the first 72 h after hospital admission by proposing several clinical care pathways. The proposed pathways are based on the SEMICYUC 2005 Recommendations with incorporation of the latest developments in the field, particularly the determinants-based classification of acute pancreatitis severity. The pathways also incorporate the "alarm signs", the use of therapeutic modalities known as PANCREAS, and the "call to ICU" criteria. Further studies will need to assess whether the adoption of these pathway reduces mortality and morbidity in patients with acute pancreatitis. The previous SEMICYUC guidelines on management of patients with acute pancreatitis in Intensive Care will need to be revised to reflect the recent developments in the field.

[Gender bias in women with myocardial infarction: ten years after]. / Desigualdad de esfuerzo terapéutico en mujeres con infarto agudo de miocardio: 10 años después.

OBJECTIVE: Previous studies show that the women with acute myocardial infarction (AMI) receive less fibrinolitic treatment than the men. The objective of this study is to analyze if it exists any difference in fibrinolysis related to gender and to compare the results with those obtained 10 years ago. DESIGN: Retrospective descriptive study that compare patients with AMI of less than 24 hours of evolution of studies Analysis of Delay in Acute Infarct of Myocardium (ARIAM) in 2003-2004 and Project of Analysis Epidemiologist of Critical Patient (PAEEC) of 1992-1993. SETTING: ICUs from 86 hospitals in Spain that participated in the PAEEC study and 120 ICUs in the ARIAM. PATIENTS: We compared data of 9,981 patients including in study ARIAM in 2003-2004 with 1,668 of the PAEEC of 1992-1993. RESULTS: Women were less likely to receive thrombolytic therapy than men (odds ratio= 0.82, p < 0.01), after adjusting for age, origin, size of the hospital and antecedents. The probability of fibrynolisis is lower in elderly, patients referred from the general ward, in hospitals of more than 1,000 beds and patients with arterial hypertension, stroke, diabetes or peripheral vascular disease. The probability of fibrinólisis is higher when patient is transferred from another hospital (followed by those of Emergencies Room), in the hospitals by less than 300 beds (followed by those of 300-1,000) and when history of prior ischemic heart disease exists. Comparing the two periods, has increased the frequency of fibrynolisis in both genders, although the increment has been greater in the women. CONCLUSIONS: The women with AMI continue receiving less fibrynolisis, although exists an increase in the number of treatments superior to register in the men.

Septic shock and community-acquired pneumonia associated with etanercept therapy.

OBJECTIVE: To report a case of septic shock and community-acquired pneumonia in a patient with psoriatic arthritis receiving treatment with etanercept. PATIENT DETAILS: A 65-year-old woman diagnosed as having psoriatic arthritis had received treatment with etanercept. Chest X-ray studies were normal and the tuberculin skin test was negative. Two months after etanercept therapy, the patient presented to our emergency department with fever, cough, chest pain and generalized weakness. Chest radiography revealed a right pulmonary infiltrate. Her condition rapidly deteriorated and she went into shock with a further drop in her blood pressure, tachycardia and tachypnea. She was intubated, mechanically ventilated and was treated with fluids, cardioversion and amiodarone. Empiric therapy with levofloxacin, amikacin and cefepime were initiated. In the urinalysis, the result of a rapid test for Streptococcus pneumoniae was positive. Etanercept treatment was suspended due to a possible adverse reaction associated with this drug. At the start of therapy her clinical condition improved slowly. On Day 28, the patient was afebrile and she was discharged from the intensive care unit. DISCUSSION: Most of the infections associated with etanercept therapy have been reported in patients with rheumatoid arthritis. Based on our observations, etanercept was the possible offender in the development of septic shock and respiratory failure in community-acquired pneumonia. There was a temporal relationship between exposure to the drug and onset of symptoms. Etanercept was the only drug administered before the septic shock developed. Based on the Naranjo algorithm, the adverse reaction could be considered possible. CONCLUSION: Patients initiated on etanercept should be counseled and receive appropriate screening before drug initiation. All febrile and newly occurring concomitant illnesses should be promptly evaluated. General practitioners should discontinue etanercept treatment and institute prompt and aggressive intervention if infection develops.

Recomendaciones de la 7ª Conferencia de Consenso de la SEMICYUC. Pancreatitis aguda grave en Medicina Intensiva / Recommendations of the 7th consensus conference of the SEMICYUC. Severe acute pancreatitis in Intensive Medicine

Objetivo. La pancreatitis aguda grave (PAG) no se ha estudiado desde la Medicina Intensiva y menos su manejo integral. El objetivo es consensuar el diagnóstico y tratamiento en una UCI, con todas las Sociedades implicadas y ofrecer unas recomendaciones que uniformicen el manejo integral de las PAG. Ámbito. Español. Pamplona, 11 y 12 de marzo de 2004. Participantes. Intensivistas nacionales, gastroenterólogos de la Asociación Española de Gastroenterología (AEGE) y Club Español Biliopancreático (CEBP), cirujanos de la Asociación Española de Cirugía, Sección de Infección Quirúrgica (IQ-AEC), radiólogos de la Sociedad Española de Radiología Médica (SERAM), y Sección de Imagen Abdominal (SEDIA) y miembros de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). Niveles de evidencia y grados de recomendación. Se eligieron las escalas del Oxford Centre for Evidence based Medicine. Elaboración de las recomendaciones. Se realizó una convocatoria pública en la que se discutieron todos los temas previamente seleccionados, que se distribuyeron en 4 bloques de preguntas: 1.ª ¿Diagnóstico, criterios precoces de gravedad y de ingreso de las PAG en UCI?. 2.ª ¿Cuáles son las medidas más relevantes y aplicables en el tratamiento del paciente con PAG en UCI?. 3.ª ¿Cuál es el tratamiento actual de la PAG?. 4.ª ¿Qué actitud quirúrgica se debe adoptar ante la PAG con necrosis no-infectada y la sepsis pancreática? Tras la discusión pública el Jurado elaboró un documento de recomendaciones. Este documento fue enviado para su comentario a los miembros del Comité Organizador, a los ponentes y a los asistentes a la Conferencia de Consenso. Por último, las recomendaciones fueron de nuevo discutidas en una sesión pública y abierta en el Congreso Nacional de la SEMICYUC. Conclusiones. Recomendaciones en PAG entre las que destacamos: la disminución de la mortalidad de la PAG depende de la estratificación temprana de las formas graves a la puerta del hospital, durante las primeras 48-96 horas y del ingreso precoz en Intensivos. Los pacientes que muestran un progresivo deterioro orgánico, aunque no precisen soporte ventilatorio, deben ingresar en UCI. Cada Centro debe consensuar un protocolo interdisciplinario. Los antibióticos como profilaxis no tienen una base de evidencia potente sólo estarían indicados en las formas necrotizantes y a la espera de un nuevo ensayo doble-ciego con meropenem en marcha. El tratamiento quirúrgico se indica en la necrosis pancreática infectada o absceso identificadas por radiología o punción radiodirigida. El manejo de las formas estériles debe ser conservador

Objective. Severe acute pancreatitis (SAP) has not been studied from the point of view of Intensive Medicine and even less its integral management. The objective is to reach a consensus on the diagnosis and treatment in an ICU with all the societies involved and to offer some recommendations that make the integral management of SAP uniform. Scope. Spanish. He took place in Pamplona, the 11-12 March 2004. Participants. National Intensivists, Gastroenterologists of the Spanish Association of Gastroenterology (AEGE) and Biliopancreatic Spanish Club (CEBP), Surgeons of the Spanish Association of Surgery, Surgical Infection Section (IQ-AEC), Radiologists of the Spanish Society of Medical Radiology (SERAM), and Abdominal Image Section (SEDIA) as well as member of the Spanish Society of Urgency and Emergency Medicine (SEMES). Evidence levels and recommendation grades. The Oxford Centre for Evidence based Medicine scales were chosen. Elaboration of the recommendations. A public examination session was called in which all the previously selected subjects were discussed. They were distributed into 4 blocks of questions: 1) Diagnostic, Early Severity criteria and Admission of SAP in the ICU? 2) What are the most relevant and applicable measures in the treatment of the patients with SAP in the ICU? 3) What is the present treatment of SAP? 4) What surgical attitude should be adopted in the face of SAP with non-infected necrosis and pancreatic sepsis? After the public discussion, the Jury elaborated a recommendations document. This document was sent to the members of the Organizing Committee, to the speakers and those attending the consensus Conference for their comments. Finally, the recommendations were discussed again in a public and open session in the National Congress of SEMICYUC.Conclusions. Recommendations in SAP, among which we emphasize: Decrease in mortality of SAP depends on the early stratifying of the serious forms to the hospital door, during the first 48-96 hours and early admission in Intensive Care. Patient who have a progressive organic deterioration, although they do not require ventilatory support, should be admitted to the ICU. Each Center should agree on an interdisciplinary protocol. Antibiotics as prophylaxis do not have a strong evidence base. They would only be indicated in necrotizing forms and while waiting for a new on-going double blind clinical trial with meropenem. Surgical treatment is indicated in infected pancreatic necrosis or abscess, identified by radiology or radioguided puncture. Management of the sterile forms should be conservative

Socioeconomic status and severity of illness on admission in acute myocardial infarction patients.

The objective of this research is to test the hypothesis of the existence of an association between socioeconomic status and severity of illness of the patients admitted to the hospital with acute myocardial infarction. The design was a retrospective cohort study of consecutive patients admitted to the coronary care unit with the diagnosis of acute myocardial infarction in six public hospitals from the Spanish region of Valenciá. A total of 369 patients admitted to the intensive care units of the participating hospitals were studied. The socioeconomic status was measured using an ad hoc index based upon the occupational level, income and educational level of the patient. The patients below the 20% percentile were considered as disadvantaged, and the patients whose Killip class on admission was 3 or 4 were considered as complicated. The effect of potential confounders was controlled using unconditional logistic regression analysis. The results were validated in an independent but comparable population of 331 patients. The disadvantaged patients showed a higher prevalence of open cardiac failure on admission (Killip classes 3 or 4) than the remainder (crude odds ratio = 3.1, 95% confidence interval between 1.57 and 6.1). The association between socioeconomic status and severity of illness persisted after controlling for important covariates (age, diabetes mellitus, gender and marital status): adjusted odds ratio = 2.4, 95% confidence interval between 1.1 and 5.2. These results were highly consistent with those in the validation group. Our results suggest that socioeconomic status is an independent predictor of the severity of illness on admission to coronary care units in acute myocardial infarction patients. These results are consistent with the existence of a low accessibility of patients in the lower socioeconomic levels.

[Differences in therapeutic effort because of the socioeconomic level of patients with acute myocardial infarction]. / Diferencias de esfuerzo terapéutico en razón del nivel socioeconómico en pacientes con infarto agudo de miocardio.

OBJECTIVES: To assess the hypothesis of the existence of differential therapeutic effort according to the socioeconomic status of the patients admitted to the hospital by acute myocardial infarction. PATIENTS AND METHODS: We study retrospectively 592 patients admitted to the intensive care units from six public hospitals from the Spanish region of Valencia, using data from two cohort studies focused on the study of in-hospital inequalities in health. The socioeconomic status was measured using the British occupational classification. The therapeutic effort predicted for the severity of illness was determined using a regression model that included the logarithm of Therapeutic Intervention Scoring System (TISS) score as the dependent variable and Simplified Acute Physiology Score (SAPS) score and Killip group as predictors. The patients whose observed TISS was 3 or more pointless than predicted were considered as infra-treated. The effect of potential confounders was controlled using unconditional logistic regression analysis. RESULTS: The proportion of infra-treated patients was inversely related to socioeconomic status chi 2 for tendency = 4.31, P = 0.0378). The logistic regression analysis showed a negative association between age and therapeutic effort (p < 0.0001) but not between therapeutic effort and socioeconomic status, after controlling the effect of age (p = 0.2150). DISCUSSION: Our results suggest that older patients receive less relative therapeutic effort, measured by TISS score, than younger patients. The differential therapeutic effort observed in the crude analysis seem attributable to the higher age of the patients in the lower socioeconomic strata.

[Effect of social factors on quality of life of survivors of myocardial infarction]. / Efecto de los factores sociales sobre la calidad de vida de los supervivientes de un infarto de miocardio.

BACKGROUND: The aim of this study was to analyze the effect of the social environment on the quality of life of the survivors of an acute myocardial infarction. METHODS: A prospective cohort study was carried out with telephone follow up of patients admitted in the Intensive Care Units of six public hospitals in the region of Valencia (Spain). Three hundred eighty consecutive patients admitted for acute myocardial infarction were studied being followed a median of 3.4 years. Follow up was complete in 91.6% of the cases. RESULTS: The global quality of life was good. The component most affected was that of physical activity. Following control of the effect of the biologic and health care covariables, the quality of life was inversely and independently associated with age, female sex, low educative level and foreigness. CONCLUSIONS: Unequality was found in regard to the quality of life based on the socioeconomic level of survivors of acute myocardial infarction.

[Prognosis of myocardial infarction in women. Effect of the therapeutic effort and the socioeconomic status]. / Pronóstico del infarto de miocardio en mujeres. Efecto del esfuerzo terapéutico y del nivel socioeconómico.

The causes of the high mortality of acute myocardial infarction in women as compared with men are controversial. The objective of this study is to assess the role of the therapeutic effort and socioeconomic factors on the genesis of this excess of mortality. We studied, using a retrospective cohort design, 491 men and 124 women admitted with the diagnosis of acute myocardial infarction. As a group, women were older (69 versus 61 years of age, p < 0.00001), showed a higher prevalence of cardiac failure on admission (44% versus 26%; p = 0.00008) and a higher mortality in the coronary care unit (29.3% versus 12.9%; p = 0.00002). In addition, the women showed an unfavorable socioeconomic profile and received a lower relative therapeutic effort, as assessed by the Therapeutic Intervention Scoring System. There was statistical interaction between gender and marital status, with a higher mortality in the unmarried male, comparable to that of women. Within the married group, the excess of mortality in women persisted after adjusting for age and Killip group (adjusted odds ratio = 2.48, 95% confidence interval between 1.26 and 4.89). None of the studied socioeconomic variables was independently associated to mortality, once age, Killip group and marital status were taken into account. After adjusting for therapeutic effort, the differences between men and women increased. Women admitted with acute myocardial infarction show a poor short-term prognosis that is not explained by their socioeconomic profile nor by the differences in therapeutic effort.

[Age as a prognostic factor in intensive care]. / La edad como factor pronóstico en cuidados intensivos.

In order to define the prognostic impact of the age of critical patients as well as its association with the initial severity of illness (SAPS index) and therapeutic effort (TISS index), we studied 1.102 patients older than 14 years admitted consecutively to 3 general intensive care units. The oldest patients (more than 65 years) showed a higher mean SAPS (11.00 versus 8.58, p less than 0.0001) and mortality (odds ratio = 1.99, p less than 0.0001) than the younger ones. The association between age and mortality showed a "dose-response" pattern, even after controlling for the effect of initial severity (p less than 0.0001). The effect of age was stronger in the groups of patients with low SAPS (odds ratio = 2.94, p = 0.0007) or admitted for acute myocardial infarction (odds ratio = 3.28, p less than 0.0001). The oldest group showed a lower TISS/SAPS ratio and a shorter stay in the intensive care unit than younger patients, suggesting a low relative therapeutic effort in the latter. The differential therapeutic effort did not explain, however, the mortality excess in the oldest group, because the gradient of mortality increased after adjusting for TISS/SAPS ratio (adjusted odds ratio = 2.42, p less than 0.0001).

Predictors of death following ICU discharge.

In order to study possible predictors of early after-discharge mortality (EADM), 700 consecutive patients discharged alive from three intensive care units (ICUs) were followed up 2 months after their admission. The observed mortality was 7.3%. Univariate analysis indicated a strong statistically significant association of the following variables with mortality: initial simplified acute physiological score (SAPS) greater than 10, therapeutic intervention score in the first 24 h of admission greater than 20, age greater than or equal to 65, length of stay in the ICU greater than 10 days, and low educational level. The multiple logistic regression analysis included as predictive independent variables the SAPS, organs or systems failure, age, and length of stay. The model built upon these four variables was able to identify a group of patients at high risk (21-46%) of EADM. We conclude that some simple variables can be used as useful markers of patients groups at high risk of EADM.

[Legionellosis at intensive care units: study of 30 cases]. / Legionelosis en cuidados intensivos: estudio de 30 casos.

A prospective study during 44 months has been carried out in order to establish the incidence of pneumonia due to Legionella sp. in our hospital's intensive care unit (ICU). Thirty cases of legionellosis were diagnosed (22.2% of the studied pneumonias) two of them were acquired in the ICU and 76.6% were caused by L. pneumophila serotype. The most evident symptomatology was intense dyspnea, neurological disorders, acute respiratory and renal failure. The biochemical alterations, most commonly encountered were increased liver enzymes, hypoxemia, hypoalbuminemia, increased urea, creatinine and hematuria. As a consequence of this severe disease, the mortality rate was high (13 out of 30 cases).