[Controversy 1: Proteins and new guidelines for acute kidney injury]. / Controversia 1. Proteínas y las nuevas guías en lesión renal aguda.

Introduction: Controversy 1: Proteins and new guidelines for acute kidney injury.

Introducción: Controversia 1. Proteínas y las nuevas guías en lesión renal aguda.

Beneficios de un programa de formación y de un algoritmo clínico de soporte nutricional mixto para mejorar la nutrición del paciente crítico: estudio antes-después / Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study

Introducción: la nutrición óptima del paciente crítico es clave para su recuperación. Objetivos: promover la formación y difusión del conocimiento acerca del soporte nutricional mixto (SNM) mediante un algoritmo clínico entre los intensivistas para mejorar el estado nutricional de los pacientes críticos. Métodos: estudio antes-después con la participación de 19 unidades de cuidados intensivos (UCI) polivalentes en 10 comunidades autónomas. Cinco miembros del comité científico formaron a los formadores mediante presentaciones orales y el algoritmo de SNM. Los formadores fueron responsables de la formación de los intensivistas en sus propias UCI. El cuestionario de 30 ítems fue completado por 179 y 105 intensivistas antes y después de la intervención, respectivamente. Resultados: se observó un aumento del conocimiento en seis (20 %) preguntas específicas relacionadas con el SNM. En 11 ítems (36,6 %), el conocimiento adecuado sobre diferentes aspectos del soporte nutricional que ya estaban presentes antes de la formación se mantuvieron, y en cinco ítems (16,7 %) hubo un aumento de la tasa de respuestas correctas. En cuatro ítems (13,3 %), las respuestas correctas no mejoraron y en otros cuatro (13,3 %), los porcentajes de respuestas correctas disminuyeron. Conclusiones: el algoritmo de SNM ha logrado una sólida consolidación de los principales conceptos de esta estrategia. Algunos aspectos referentes a cómo manejar al paciente desnutrido, cómo identificarlo y qué tipo de nutrición pautar desde el inicio del ingreso en la UCI, los aportes nutricionales en situaciones especiales y el seguimiento de posibles complicaciones como la realimentación, son áreas que requerirían estrategias formativas adicionales. (AU)

Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed. (AU)

[Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study]. / Beneficios de un programa de formación y de un algoritmo clínico de soporte nutricional mixto para mejorar la nutrición del paciente crítico: estudio antes-después.

INTRODUCTION: Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed.

INTRODUCCIÓN: Introducción: la nutrición óptima del paciente crítico es clave para su recuperación. Objetivos: promover la formación y difusión del conocimiento acerca del soporte nutricional mixto (SNM) mediante un algoritmo clínico entre los intensivistas para mejorar el estado nutricional de los pacientes críticos. Métodos: estudio antes-después con la participación de 19 unidades de cuidados intensivos (UCI) olivalentes en 10 comunidades autónomas. Cinco miembros del comité científico formaron a los formadores mediante presentaciones orales y el algoritmo de SNM. Los formadores fueron responsables de la formación de los intensivistas en sus propias UCI. El cuestionario de 30 ítems fue completado por 179 y 105 intensivistas antes y después de la intervención, respectivamente. Resultados: se observó un aumento del conocimiento en seis (20 %) preguntas específicas relacionadas con el SNM. En 11 ítems (36,6 %), el conocimiento adecuado sobre diferentes aspectos del soporte nutricional que ya estaban presentes antes de la formación se mantuvieron, y en cinco ítems (16,7 %) hubo un aumento de la tasa de respuestas correctas. En cuatro ítems (13,3 %), las respuestas correctas no mejoraron y en otros cuatro (13,3 %), los porcentajes de respuestas correctas disminuyeron. Conclusiones: el algoritmo de SNM ha logrado una sólida consolidación de los principales conceptos de esta estrategia. Algunos aspectos referentes a cómo manejar al paciente desnutrido, cómo identificarlo y qué tipo de nutrición pautar desde el inicio del ingreso en la UCI, los aportes nutricionales en situaciones especiales y el seguimiento de posibles complicaciones como la realimentación, son áreas que requerirían estrategias formativas adicionales.

Impact of previous admission to an intensive care unit on stem cell transplantation outcome / Impacto de un ingreso previo en una unidad de medicina intensiva sobre los resultados del trasplante hematopoyético

INTRODUCTION: The impact of an admission to ICU before stem cell transplantation (SCT) on post-SCT outcome is not well established. PATIENTS AND METHODS: We reviewed the medical records of patients who had received a first SCT between 2000 and 2016 in our institution. The outcome of 22 patients who required ICU admission during chemotherapy prior to SCT (ICU group) was compared with 44 matched patients (1:2) who did not need it (NO-ICU group). RESULTS: There were no differences in transplant complications, in time to neutrophil and platelet recovery or in the length of hospital stay during SCT between the ICU and NO-ICU groups. However, microbiologically documented infections were more common in the ICU group (16/20) than in the NO-ICU group (18/39) (p=.027). The 5-yr overall survival probability (CI 95%) was 49% (28-70%) in the ICU vs. 45% (29-61%) in the NO-ICU group (p=.353), while the 5-yr incidence of non-relapse mortality was 32% (14-52%) and 24% (12-38%) (p=.333), respectively. Six patients (27%) in the ICU group and 8 (18%) in the NO-ICU group required admission to the ICU during or after the SCT procedure (p=.293). Twelve (54%) patients in the ICU and 22 (50%) in the NO-ICU group died, the causes of death were similar in both groups. CONCLUSION: Our results show that admission to the ICU prior to SCT does not have a negative impact on patient outcomes following SCT and should not be considered as an exclusion criterion for SCT

INTRODUCCIÓN: No se conoce con exactitud el impacto de la necesidad de ingreso previo en una unidad de cuidados intensivos (UCI) en la supervivencia postrasplante de progenitores hematopoyéticos (TPH). PACIENTES Y MÉTODOS: Se revisaron los archivos de pacientes que habían recibido un TPH entre el 2000 y 2016 en una única institución. El resultado del TPH en 22 pacientes que habían precisado de ingreso en una UCI durante las quimioterapias administradas previas al TPH (grupo UCI) se comparó con el de 44 pacientes controles (1:2) trasplantados que no habían precisado ingreso previo en UCI (grupo NO-UCI). RESULTADOS: No hallamos diferencias en las complicaciones post-TPH, en el tiempo de injerto de neutrófilos o de plaquetas, ni tampoco en la duración del ingreso hospitalario entre el grupo UCI y el grupo NO-UCI (p = 0,353). Sin embargo, la incidencia de infecciones documentadas microbiológicamente fue mayor en el grupo UCI (16/20) que en el NO-UCI. La probabilidad de supervivencia a 5 años (IC95%) fue del 49% (28-70%) para el grupo UCI vs. el 45% (29-61%) para el grupo NO-UCI (p = 0,353), mientras que la mortalidad relacionada con el TPH a los 5 años fue del 32% (14-52%) y 24% (12-38%) (p = 0,333), respectivamente. Seis pacientes (27%) en el grupo UCI y 8 (18%) en el grupo NO-UCI precisaron ingreso en UCI durante o después del proceso de TPH (p = 0,293). Doce pacientes (54%) en el grupo UCI y 22 (50%) en el NO-UCI fallecieron, y las causas de muerte fueron similares en ambos grupos. CONCLUSIÓN: El ingreso en UCI no tiene necesariamente un impacto negativo en los resultados de un TPH posterior en pacientes hematológicos y no debería ser criterio de exclusión para dicho procedimiento

Impact of previous admission to an intensive care unit on stem cell transplantation outcome.

INTRODUCTION: The impact of an admission to ICU before stem cell transplantation (SCT) on post-SCT outcome is not well established. PATIENTS AND METHODS: We reviewed the medical records of patients who had received a first SCT between 2000 and 2016 in our institution. The outcome of 22 patients who required ICU admission during chemotherapy prior to SCT (ICU group) was compared with 44 matched patients (1:2) who did not need it (NO-ICU group). RESULTS: There were no differences in transplant complications, in time to neutrophil and platelet recovery or in the length of hospital stay during SCT between the ICU and NO-ICU groups. However, microbiologically documented infections were more common in the ICU group (16/20) than in the NO-ICU group (18/39) (p=.027). The 5-yr overall survival probability (CI 95%) was 49% (28-70%) in the ICU vs. 45% (29-61%) in the NO-ICU group (p=.353), while the 5-yr incidence of non-relapse mortality was 32% (14-52%) and 24% (12-38%) (p=.333), respectively. Six patients (27%) in the ICU group and 8 (18%) in the NO-ICU group required admission to the ICU during or after the SCT procedure (p=.293). Twelve (54%) patients in the ICU and 22 (50%) in the NO-ICU group died, the causes of death were similar in both groups. CONCLUSION: Our results show that admission to the ICU prior to SCT does not have a negative impact on patient outcomes following SCT and should not be considered as an exclusion criterion for SCT.

A multicenter, randomized, double-blind study of ulimorelin and metoclopramide in the treatment of critically ill patients with enteral feeding intolerance: PROMOTE trial.

PURPOSE: Enteral feeding intolerance (EFI) is a frequent problem in the intensive care unit (ICU), but current prokinetic agents have uncertain efficacy and safety profiles. The current study compared the efficacy and safety of ulimorelin, a ghrelin agonist, with metoclopramide in the treatment of EFI. METHODS: One hundred twenty ICU patients were randomized 1:1 to ulimorelin or metoclopramide for 5 days. EFI was diagnosed by a gastric residual volume (GRV) ≥ 500 ml. A volume-based feeding protocol was employed, and enteral formulas were standardized. The primary end point was the percentage daily protein prescription (%DPP) received by patients over 5 days of treatment. Secondary end points included feeding success, defined as 80% DPP; gastric emptying, assessed by paracetamol absorption; incidences of recurrent intolerance (GRV ≥ 500 ml); vomiting or regurgitation; aspiration, defined by positive tracheal aspirates for pepsin; and pulmonary infection. RESULTS: One hundred twenty patients were randomized and received the study drug (ulimorelin 62, metoclopramide 58). Mean APACHE II and SOFA scores were 21.6 and 8.6, and 63.3% of patients had medical reasons for ICU admission. Ulimorelin and metoclopramide resulted in comparable %DPPs over 5 days of treatment (median [Q1, Q3]: 82.9% [38.4%, 100.2%] and 82.3% [65.6%, 100.2%], respectively, p = 0.49). Five-day rates of feeding success were 67.7% and 70.6% when terminations unrelated to feeding were excluded, and there were no differences in any secondary outcomes or adverse events between the two groups. CONCLUSIONS: Both prokinetic agents achieved similar rates of feeding success, and no safety differences between the two treatment groups were observed.

Lack of impact of human immunodeficiency virus infection on the outcome of lymphoma patients transferred to the intensive care unit.

The impact of human immunodeficiency virus (HIV) infection on the outcome of patients with acquired immunodeficiency syndrome (AIDS)-related lymphoma with life-threatening complications requiring intensive care unit (ICU) admission is not well known. The objective of this study was to compare the outcome of patients with lymphoma transferred to the ICU according to HIV infection status. The clinical characteristics, reason for ICU admission, and outcome of 48 consecutive critically ill patients with lymphoma admitted to the ICU from January 2000 to March 2010 was retrospectively analyzed, focusing on their HIV serology status. Thirty-six patients were HIV-negative and 12 patients HIV-positive. Burkitt lymphoma was more frequent in HIV-infected patients, whereas diffuse large B-cell lymphoma was more frequent in HIV-negative patients. The main acute life-threatening diseases precipitating ICU transfer were similar in both groups. Severe neutropenia was more frequent in HIV-positive than in HIV-negative patients. With a median follow-up of 53 months after ICU admission, the overall survival probabilities were 15% (95% confidence interval [CI]: 3-27%) and 17% (95% CI: 0-38%) for HIV-negative and HIV-positive patients, respectively. The 2-year survival probabilities were 34% (95% CI: 10-58%) and 40% (95% CI: 0-43%) for HIV-negative and HIV-positive patients discharged from the ICU, respectively. In this study, HIV infection did not have a negative impact on the outcome of patients with lymphoma admitted to the ICU.

[Similar prognosis for transplanted and non-transplanted patients with hematological malignancy admitted to the intensive care unit]. / Similar supervivencia de los pacientes con neoplasia hematológica trasplantados y no trasplantados que requieren ingreso en una unidad de vigilancia intensiva.

BACKGROUND AND OBJECTIVE: There is scarce information on the influence of stem cell transplantation (SCT) on the prognosis of patients with hematological malignancies admitted to an intensive care unit (ICU). PATIENTS AND METHOD: The mortality during ICU admission, long-term survival and the prognostic factors for survival were analyzed and compared in transplanted vs. non-transplanted patients. RESULTS: 116 critically-ill patients with a hematological malignancy transferred to the ICU in a single institution were analyzed. Thirty patients had received SCT prior to ICU admission. Transplanted and non-transplanted patients were comparable for demographic variables (except age and disease status) and reasons for ICU admission. No differences were found in overall survival or survival after discharge from ICU between transplanted and non-transplanted patients. Thirty-nine out of 85 non-transplanted patients (46%) and 11 out of 31 transplanted patients (35%) could be discharged from the ICU. The prognostic factors for survival in non-transplanted patients were need of mechanical ventilation or cardiovascular vasoactive drugs. However, only the liver function impairment predicted the outcome in the transplanted patients through the multivariate analysis. CONCLUSIONS: A significant proportion of patients admitted to ICU were discharged despite previous SCT. These patients did not have a worse prognosis than those transferred to the ICU with a hematologic malignancy, although the prognostic factors for survival were different in the 2 groups of patients.

Similar supervivencia de los pacientes con neoplasia hematológica trasplantados y no trasplantados que requieren ingreso en una unidad de vigilancia intensiva / Similar prognosis for transplanted and non-transplanted patients with hematological malignancy admitted to the intensive care unit

Fundamento y objetivo: La información sobre la influencia del trasplante de progenitores hematopoyéticos (TPH) previo en la supervivencia de los pacientes con hemopatías malignas que ingresan en una unidad de vigilancia intensiva (UVI) es escasa. Pacientes y método: Se han comparado la mortalidad durante el ingreso en la UVI, la supervivencia a largo plazo y los factores pronósticos que influyen en la supervivencia entre pacientes con hemopatías malignas trasplantados y no trasplantados. Resultados: Ingresaron en la UVI de un único centro 116 pacientes críticos con hemopatía maligna, de los que 31 habían recibido un TPH. Los pacientes trasplantados y no trasplantados fueron comparables, excepto en edad y estadio de la enfermedad hematológica. No hubo diferencias en la supervivencia global o la supervivencia después del alta de la UVI entre pacientes trasplantados y no trasplantados. Se pudo dar de alta a 39 de los 85 pacientes sin TPH previo (46%) y a 11 de los 31 con TPH previo (35%). Los factores pronósticos de supervivencia global en el análisis multivariante para los no receptores de TPH fueron la necesidad de ventilación mecánica o de fármacos vasoactivos, mientras que para los receptores de TPH el único factor predictivo de la supervivencia fue la alteración de la función hepática. Conclusiones: Una proporción apreciable de pacientes con hemopatía maligna que requieren ingreso en la UVI pueden ser dados de alta, incluso si han recibido un TPH. Estos últimos pacientes no tienen un pronóstico diferente del de otros subgrupos de pacientes con hemopatía maligna, aunque los factores pronósticos son distintos

Background and objective: There is scarce information on the influence of stem cell transplantation (SCT) on the prognosis of patients with hematological malignancies admitted to an intensive care unit (ICU). Patients and method: The mortality during ICU admission, long-term survival and the prognostic factors for survival were analyzed and compared in transplanted vs. non-transplanted patients. Results: 116 critically-ill patients with a hematological malignancy transferred to the ICU in a single institution were analized. Thirty patients had received SCT prior to ICU admission. Transplanted and non-transplanted patients were comparable for demographic variables (except age and disease status) and reasons for ICU admission. No differences were found in overall survival or survival after discharge from ICU between transplanted and non-transplanted patients. Thirty-nine out of 85 non-transplanted patients (46%) and 11 out of 31 transplanted patients (35%) could be discharged from the ICU. The prognostic factors for survival in non-transplanted patients were need of mechanical ventilation or cardiovascular vasoactive drugs. However, only the liver function impairment predicted the outcome in the transplanted patients through the multivariate analysis. Conclusions: A significant proportion of patients admitted to ICU were discharged despite previous SCT. These patients did not have a worse prognosis than those transferred to the ICU with a hematologic malignancy, although the prognostic factors for survival were different in the 2 groups of patients

Outcome and prognostic factors in patients with hematologic malignancies admitted to the intensive care unit: a single-center experience.

Patients who are admitted to the intensive care unit (ICU) with hematologic malignancies have a poor prognosis, although outcomes have improved in recent years. This study analyzed ICU mortality, short- and long-term survival, and prognostic factors for 100 consecutive critically ill patients with a hematologic malignancy who were admitted to our polyvalent ICU from January 2000 to May 2006. The median age was 55 years (range, 15-75 years; male-female ratio, 60:40). The main acute life-threatening diseases precipitating ICU transfer were respiratory failure (45 patients, 45%) and septic shock (33 patients, 33%). Forty-two patients (42%) were discharged from the ICU. The ICU mortality rate from 2004 to 2006 was lower than from 2000 to 2003 (49% versus 69%, P < .047). The 1- and 2-year probabilities of survival for patients discharged from the ICU were 67% (95% confidence interval [CI], 51%-84%) and 54% (95% CI, 34%-73%), respectively. A multivariate analysis revealed hemodynamic instability (odds ratio, 2.11; 95% CI, 1.17-3.83; P = .014) and mechanical ventilation (odds ratio, 4.27; 95% CI, 1.70-10.74; P = .002) to be the main predictors of a poor survival prognosis. Almost half of patients with hematologic malignancy and life-threatening complications can be discharged from the ICU. Age and underlying disease characteristics do not influence ICU outcome, which is mainly determined by hemodynamic and ventilatory status.