Epidemiología y pronóstico de los pacientes con antecedentes de neoplasia ingresados en las Unidades de Cuidados Intensivos. Estudio multicéntrico observacional / Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study

Objetivo Conocer la epidemiología y evolución al alta de los pacientes oncológicos que precisan ingreso en UCI. Diseño Estudio descriptivo observacional de datos del registro ENVIN-HELICS combinado con variables registradas específicamente. Se comparan pacientes con y sin neoplasia. Se identifican grupos de pacientes neoplásicos con peor evolución. Ámbito UCI participantes en ENVIN-HELICS del año 2018 con participación voluntaria en el registro oncológico. Pacientes Ingresados más de 24horas. Entre estos aquellos diagnosticados de neoplasia en los últimos 5 años. Variables principales Las generales epidemiológicas del registro ENVIN-HELICS y variables relacionadas con la neoplasia. Resultados En las 92 UCI con datos completos se seleccionaron 11.796 pacientes, de los que 1.786 (15,1%) son pacientes con neoplasia. La proporción de pacientes con cáncer por unidad fue muy variable (rango: 1-48%). La mortalidad en UCI de los pacientes oncológicos fue superior a los no oncológicos (12,3% versus 8,9%; p<0,001). En pacientes oncológicos predominaron los ingresados en el postoperatorio programado (46,7%) o urgente (15,3%). Los pacientes con proceso patológico médico fueron más graves, con mayor estancia y mortalidad (27, 5%). Aquellos ingresados en UCI por enfermedad no quirúrgica relacionada con el cáncer tuvieron la mortalidad más alta (31,4%). Conclusión Existe una gran variabilidad en el porcentaje de pacientes oncológicos en las diferentes UCI. El 46,7% de los pacientes ingresa tras someterse a cirugía programada. La mayor mortalidad corresponde a pacientes con enfermedad médica (27,5%) y a los ingresados por complicaciones relacionadas con el cáncer (31,4%). (AU)

Objective To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU). Design A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified. Setting Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry. Patients Subjects admitted during over 24hours and diagnosed with cancer in the last 5 years. Primary endpoints The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables. Results Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; P<.001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted in ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%). Conclusions Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%). (AU)

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study.

OBJECTIVE: To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU). DESIGN: A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified. SETTING: Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry. PATIENTS: Subjects admitted during over 24 h and diagnosed with cancer in the last 5 years. PRIMARY ENDPOINTS: The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables. RESULTS: Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1%-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; p < .001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted to the ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%). CONCLUSIONS: Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

Medicina intensiva y donación de órganos. Más allá de nuestras fronteras habituales / Intensive care medicine and organ donation. Beyond our usual frontiers

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Non-Heart-Beating Donor Program: Results After 3 Years of Experience.

BACKGROUND: Non-heart-beating donation (NHBD) is a useful way to obtain organs and tissues. Therefore, since 2012 we have had an NHBD protocol in the metropolitan area of Seville. The aim of this work was to present the results obtained after 3 years of program. METHODS: Prospective observational study carried out from 2012 to 2014. We included all patients with an extrahospitalary sudden death who did not survive despite cardiopulmonary resuscitation, becoming a potential donors (PD). Variables included number of consultations, PD, allowed donor (AD), real donor (RD), and family or legal refusals; minutes of out-hospital care, in-hospital care, cannulation, and perfusion of the RD; and number of organs and tissues removed and viable proportion. Nonallowed donors were grouped according to the discarding cause. RESULTS: We received 97 consultations, of which 40 were performed as PD. Of these, 24 were AD (60%) and 22 RD (55%). There were only 2 family refusals. In 2012, 10 patients were donors, 5 in 2013, and 7 in 2014. The out-hospital median time was 71 (interquartile range [IQR] 60-76) minutes, in-hospital 29 (26-34) minutes, cannulation 28 (24-33) minutes, and perfusion 135 (105-177) minutes. Eighteen tissues and 43 organs were extracted, of which 32 were implanted (75%), with kidneys (96%) being more frequent. Nonallowed donors numbered 12 in 2012, 4 in 2013, and 1 in 2014, and out-hospital causes were the most frequent discard reason. CONCLUSIONS: NHBD is a useful program in our city with a low refusal rate (8%), an average of 1.45 organs per donor, and kidney the most frequent organ.

Donation in Private Clinics as an Alternate Strategy to Increase the Pool of Donors.

In recent years, the donation process is being characterized by a decreased number of brain deaths and a logistical shift toward cardiac-death donation, both controlled and uncontrolled, in Spain. As we know, cardiac-death donors produce fewer usable organs than brain-death donors. Therefore, many of the Spanish transplant coordinators are working to find new strategies that bring efficiency to donor detection. Since 2012, at the Virgen del Rocío University Hospital, Seville, we have been trying to obtain more donors with the use of a huge logistical and administrative effort of all the elements that make up the donation and transplantation teams, because we have sought to get organ donors in all private clinics in the city. The result of this effort has succeeded in increasing the donation rate in Seville to 3 donors and >6 usable organs per year. This paper also analyzes the characteristics of these donors, comparing our results with our community and the country. The conclusion of all this, we believe, encourages persevering in those efforts and endorses a strategy that could be applied in other parts of the world with good results in terms of transplanted organs.

Donante vivo. Legislación / Living donor. Legislation

Introducción: Trasplantes realizados de órganos procedentes de donante vivo pueden serlo de un riñón y parciales de hígado, intestino e incluso pulmón. Si bien varían fundamentalmente en el riesgo que supone para el donante y los resultados en la supervivencia del injerto, la implicación legal es la misma. Así, me centraré en el protocolo con mayor experiencia, menor riesgo para el donante y mejores resultados: la donación renal de vivo. El trasplante renal ha demostrado ser el mejor tratamiento de la insuficiencia renal crónica en cuanto a supervivencia, calidad de vida, menores complicaciones y mejor relación coste-beneficio frente a la diálisis. Situación actual del donante vivo: El trasplante renal procedente de donante vivo se realiza en 14 de las 17 comunidades autónomas del territorio nacional. Destacan, en el año 2013, Cataluña (165 trasplantes), Andalucía (60 trasplantes), Madrid (40 trasplantes) y País Vasco (38 trasplantes), y la evolución del plan nacional de trasplante cruzado, con un incremento muy significativo en el número de trasplantes, desde su comienzo en el año 2009 con dos trasplantes renales hasta 41 trasplantes renales procedentes de donante vivo cruzado en el año 2013. Legislación: El trasplante renal de donante vivo estaba regulado en España por la Ley de trasplantes 30/1979. Esta ley regulaba la donación en vida de un órgano si es compatible con la vida y la función del órgano o parte de él es compensada por el organismo. Especifica además que el destino del órgano será su trasplante a una persona determinada. Luego siguió el Real Decreto 2070/1999, la Ley de Autonomía del Paciente 41/2002 y finalmente el Real Decreto 1723/2012 de 28 de diciembre. En Europa, la Directiva 2010/45/UE del Parlamente Europeo y del Consejo Europeo de 7 de julio de 2010 (AU)

Introduction: Organ transplants from living donors may be a partial kidney and liver, intestine and even lung. If they vary mainly in the risk to the donor and results in graft survival, the legal implication is the same. So I will focus for this chapter in the protocol with more experience, the less risk to the donor and better results: the living kidney donation. Kidney transplantation has proven to be the best treatment of chronic renal failure in terms of survival, quality of life, fewer complications and better cost-benefit ratio compared to dialysis. Current status of the living donor: Kidney transplant from a living donor is performed in 14 of the 17 regions of the country. Highlighted in the year 2013 Catalonia (165 transplantations), Andalusia (60 transplants), Madrid (40 transplants) and the Basque Country (38 transplants). The evolution of cross-national transplantation plan, with a significant increase in the number of transplants, since its inception in 2009 with two kidney transplants, 41 kidney transplants from living donors crossed in 2013. Legislation: The living donor kidney transplantation was regulated in Spain by Law 30/1979 transplant. This law regulated living donation of an organ if it is compatible with the life and function of the body or part of it offset by the body. Further specifies that the fate of organ transplantation to be a certain person. Then he followed the Royal Decree 2070/1999, Law 41/2002 of Patient Autonomy and finally Royal Decree 1723/2012, 28 December. At the European level, Directive 2010/45/EU of the European Parliament and right of the European Council of July 7, 2010 (AU)

Epidemiología y pronóstico tardío de la sepsis en ancianos / Epidemiology and long-term outcome of sepsis in elderly patients

OBJETIVOS: Examinar los datos epidemiológicos de pacientes sépticos mayores de 65 años con ingreso en UCI e identificar predictores de supervivencia a 2 años. DISEÑO: Estudio de cohortes prospectivo. PACIENTES: Criterios de sepsis al ingreso a UCI. Ámbito: UCI de 40 camas en un hospital terciario. RESULTADOS: El estudio incluyó a 237 pacientes ancianos (≥ 65 años de edad) y 281 controles (< 65 años), n = 518. Al menos una enfermedad subyacente estaba presente en el 70% de los pacientes ancianos en comparación con solo el 56,1% en controles (p < 0,01). Entre los mayores de 65 años se registró mayor prevalencia de enfermedades crónicas (diabetes, enfermedad obstructiva pulmonar crónica e insuficiencia cardíaca crónica), presentación más frecuente como shock séptico (52,3 vs. 42%; p < 0,05) y abdomen como foco (52 vs. 36%; p < 0,01). El 9% de los pacientes dados de alta hospitalaria falleció en el seguimiento posterior de 2 años, aumentando hasta el 20% en los ancianos. Los predictores independientes de mortalidad a 2 años en los pacientes ancianos fueron: insuficiencia cardíaca crónica (hazard ratio ajustada [aHR] 2,24; intervalo de confianza del 95% [IC 95%] 1,28-3,94; p < 0,01), insuficiencia renal aguda (aHR 3,64; IC 95% 2,10-6,23; p < 0,01), insuficiencia respiratoria aguda (aHR 3,67; IC 95%: 2,31-5,86; p < 0,01) y antibioterapia empírica inadecuada (aHR 2,19; IC 95% 1,32-3,62; p < 0,01).Conclusiones La sepsis en mayores de 65 años presenta diferencias relevantes en sus características demográficas y presentación clínica. Tras ajustar por potenciales factores de confusión, la terapia antimicrobiana empírica inadecuada se asoció con una reducción del doble en la supervivencia a los 2 años

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (< 65 years of age) (n = 518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P < .01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P < .05), and the abdomen as the source of sepsis (52% vs 36%; P < .01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P < .01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P < .01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P < .01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P < .01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years

[Epidemiology and long-term outcome of sepsis in elderly patients]. / Epidemiología y pronóstico tardío de la sepsis en ancianos.

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (<65 years of age) (n=518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P<.01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P<.05), and the abdomen as the source of sepsis (52% vs 36%; P<.01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P<.01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P<.01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P<.01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P<.01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years.

Serologic behavior of S100B protein in patients who are brain dead: preliminary results.

OBJECTIVE: The objective of this study is to assess the S100B protein serum concentrations from brain dead (BD) donors to understand whether its level could provide clinical information during BD diagnosis as a potential confirmatory test. METHODS: During 12 months, 26 patients declared BD were prospectively included in this study. Once the diagnosis of BD was achieved, serum S100B protein levels were measured using an electrochemiluminescence assay. For analytical purposes, we selected the maximum S100B serum value reached during the first 5 days of evolution from a historical cohort of 124 survived patients after a severe brain injury (SBI), as well as from 18 healthy donors (HD) and a subgroup of patients who had severe traumatic brain injuries (TBIs) without extracranial injuries. RESULTS: Mean age was 53.48 years (SD, 18.91 years). The BD group had significantly higher S100B serum levels (1.44 µg/L; interquartile ratio [IR], 0.63-3.68) than the SBI (0.34 µg/L; IR, 0.21-0.60) and HD groups (0.06 µg/L; IR, 0.03-0.07; P < .001). Analysis of S100B levels depending on the main cause responsible for BD development showed significant differences between subgroups (P = .012). S100B serum levels were higher in the isolated TBI BD group (P = .004). The S100B value showed an odds ratio for BD diagnosis of 8.38 (95% confidence interval [CI], 1.16-60.45; P = .035). Reciever operating characteristic analysis revealed an area under the curve of 0.92 (95% CI, 0.79-1.00; P = .007). We set a cut-off value of 2 µg/L in S100B serum concentrations. At this level, the diagnostic properties of S100B would reach 100% of specificity and positive predictive value (PPV), and sensitivity and negative predictive value (NPV) of 60% and 86.7%, respectively. CONCLUSION: This preliminary analysis shows for the very first time that BD is associated with higher S100B serum levels, compared with other neurocritical care patients. We also found that the cause of BD development must be considered. Specifically, S100B serum levels in severe isolated TBI patients-with clinical exploration compatible with BD-could be used in a future as confirmatory test.