Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por covid-19: revisión rápida y consenso de expertos / Ethical recommendations for a difficult decision-making in intensive care units due to the exceptional situation of crisis by the covid-19 pandemia: a rapid review & consensus of experts

Ante la situación excepcional de salud pública provocada por la pandemia por COVID-19, desde el grupo de ética de la Sociedad Española de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) se ha promovido un trabajo de consenso, con el objetivo de encontrar algunas respuestas desde la ética a la encrucijada entre el incremento de personas con necesidades de atención intensiva y la disponibilidad efectiva de medios. En un periodo muy corto de tiempo, se ha cambiado el marco de ejercicio de la medicina hacia un escenario de "medicina de catástrofe", con el consecuente cambio en los parámetros de toma de decisiones. En este contexto la asignación de recursos o la priorización de tratamiento pasan a ser elementos cruciales, y es importante contar con un marco de referencia ético para poder tomar las decisiones clínicas necesarias. Para ello, se ha realizado un proceso de revisión narrativa de la evidencia, seguida de u. consenso de expertos no sistematizado, que ha tenido como resultado tanto la publicación de un documento de posicionamiento y recomendaciones de la propia SEMICYUC, como el consenso entre 18 sociedades científicas y 5 institutos/cátedras de bioética y cuidados paliativos de un documento marco de referencia de recomendaciones éticas generales en este contexto de crisis

In view of the exceptional public health situation caused by the COVID-19 pandemic, a consensus work has been promoted from the ethics group of the Spanish Society of the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC), with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means. In a very short period, the medical practice framework has been changed to a "catastrophe medicine" scenario, with the consequent change in the decision-making parameters. In this context, the allocation ofresources or the prioritization of treatment become crucial elements, and it is important to have an ethical reference framework to be able to make the necessary clinical decisions.For this, a process of narrative review of the evidence has been carried out, followed by u. Unsystematic consensus of experts, which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself, and the consensus between 18 scientific societies and 5 institutes / chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis

Influence of antibiotic pressure on multi-drug resistant Klebsiella pneumoniae colonisation in critically ill patients.

Background: The aim of this study is to evaluate the risk factors for colonisation by multidrug resistant (MDR) K. pneumoniae in a critical care unit and the relationship between colonisation and the antibiotic pressure exerted by the antimicrobial treatments received by patients. Methods: A prospective observational was designed. Patients admitted for more than 48 h to an intensive care unit were included. Samples for surveillance cultures were obtained from all the patients upon admission and once a week. The association between risk factors and colonisation by MDR K. pneumoniae was determined by logistic regression. A Cox regression model was used to evaluate the effect of the use of antimicrobials on the colonisation rate. An ARMIA model was used to investigate the association between the incidence of colonisation by MDR strains and the global consumption of antimicrobials in the unit. Results: One thousand seven hundred twenty-five patients were included, from which 308 (17.9%) were positive for MDR K. pneumoniae. In the multivariate analysis, hospitalisation for longer than 7 days together with respiratory infection and administration of any antibiotic was associated with increased MR K. pneumoniae colonisation. Patients who received antibiotics for more than 48 h were colonised earlier than patients who did not receive antibiotic treatment [HR: 2.16 (95%CI:1.55-3.03)]. The ARIMA model found a significant association between the monthly colonisation rate for MR K. pneumoniae and the consumption of cephalosporins and carbapenems in the previous month. Conclusion: Individual antibiotic administration and the global antibiotic pressure of cephalosporins and carbapenems are associated to an increased colonisation by MDR K. pneumoniae strains.

Impact of an antimicrobial stewardship program on critical haematological patients / Impacto de un programa de optimización de antimicrobianos sobre el paciente crítico hematológico

Objective: Antimicrobial Stewardship Programs (ASPs) have appeared as very useful tools in order to improve the use of antimicrobial agents. The objective of this study is to assess the impact of an ASP on haematological patients hospitalized in an Intensive Care Unit (ICU). Methods: A quasi-experimental pre-post intervention study, which included haematological patients admitted to an ICU and assessed by the ASP program during 3 years. The impact of the program on patient evolution was assessed by comparison between the previous period and the intervention period in terms of mortality, mean stay, number of re-hospitalizations, and duration of mechanical ventilation for intubated patients. Results: The ASP team assessed 324 antimicrobial agents in 169 patients; they recommended 121 modifications, including 55 treatment discontinuations. Compared with the pre-intervention period, there were no significant differences in the variables assessed. No variation was observed in colonization by multi-resistant bacteria. Conclusions: The implementation of an APS on critical haematological patients will lead to a relevant number of treatment modifications, without any impact on the clinical evolution of patients (AU)

Objetivo: Los programas de optimización de antimicrobianos (PROA) han surgido como herramientas de gran utilidad para mejorar el uso de estos. El objetivo del presente estudio es evaluar el impacto de un PROA sobre pacientes hematológicos ingresados en una unidad de pacientes críticos. Métodos: Estudio cuasi-experimental pre-post intervención. Se incluyeron pacientes hematológicos ingresados en una unidad de críticos evaluados por el equipo PROA durante 3 años. El impacto del programa sobre la evolución de los pacientes se evaluó mediante la comparación entre el periodo previo y de intervención de la mortalidad, estancia media, número de reingresos y duración de ventilación mecánica en los pacientes intubados. Resultados: 324 antimicrobianos de 169 pacientes fueron evaluaron por el equipo PROA, recomendando un total de 121 modificaciones, incluyendo 55 suspensiones de tratamiento. Comparados con el periodo pre-intervención, no se observaron diferencias significativas en las variables consideradas. No se observó variación en la colonización por bacterias multirresistentes. Conclusiones: La implantación de un PROA sobre el paciente crítico hematológico conduce a un número relevante de modificaciones en el tratamiento, sin afectar la evolución clínica de los pacientes (AU)

Impact of an antimicrobial stewardship program on critical haematological patients.

OBJECTIVE: Antimicrobial Stewardship Programs (ASPs) have appeared as very useful tools in order to improve the use of antimicrobial agents. The objective of this study is to assess the impact of an ASP on haematological patients hospitalized in an Intensive Care Unit (ICU). METHODS: A quasi-experimental pre-post intervention study, which included haematological patients admitted to an ICU and assessed by the ASP program during 3 years. The impact of the program on patient evolution was assessed by comparison between the previous period and the intervention period in terms of mortality, mean stay, number of re-hospitalizations, and duration of mechanical ventilation for intubated patients. RESULTS: The ASP team assessed 324 antimicrobial agents in 169 patients; they recommended 121 modifications, including 55 treatment discontinuations. Compared with the pre-intervention period, there were no significant differences in the variables assessed. No variation was observed in colonization by multi-resistant bacteria. CONCLUSIONS: The implementation of an APS on critical haematological patients will lead to a relevant number of treatment modifications, without any impact on the clinical evolution of patients.

Introducción: Los programas de optimización de antimicrobianos (PROA) han surgido como herramientas de gran utilidad para mejorar el uso de estos. El objetivo del presente estudio es evaluar el impacto de un PROA sobre pacientes hematológicos ingresados en una unidad de pacientes críticos.Material y métodos: Estudio cuasi-experimental pre-post intervención. Se incluyeron pacientes hematológicos ingresados en una unidad de críticos evaluados por el equipo PROA durante 3 años. El impacto del programa sobre la evolución de los pacientes se evaluó mediante la comparación entre el periodo previo y de intervención de la mortalidad, estancia media, número de reingresos y duración de ventilación mecánica en los pacientes intubados.Resultados: 324 antimicrobianos de 169 pacientes fueron evaluaron por el equipo PROA, recomendando un total de 121 modificaciones, incluyendo 55 suspensiones de tratamiento. Comparados con el periodo pre-intervención, no se observaron diferencias significativas en las variables consideradas. No se observó variación en la colonización por bacterias multirresistentes.Conclusiones: La implantación de un PROA sobre el paciente crítico hematológico conduce a un número relevante de modificaciones en el tratamiento, sin afectar la evolución clínica de los pacientes.

Association between recurrence of acute kidney injury and mortality in intensive care unit patients with severe sepsis.

BACKGROUND: Acute kidney injury (AKI) occurs in more than half critically ill patients admitted in intensive care units (ICU) and increases the mortality risk. The main cause of AKI in ICU is sepsis. AKI severity and other related variables such as recurrence of AKI episodes may influence mortality risk. While AKI recurrence after hospital discharge has been recently related to an increased risk of mortality, little is known about the rate and consequences of AKI recurrence during the ICU stay. Our hypothesis is that AKI recurrence during ICU stay in septic patients may be associated to a higher mortality risk. METHODS: We prospectively enrolled all (405) adult patients admitted to the ICU of our hospital with the diagnosis of severe sepsis/septic shock for a period of 30 months. Serum creatinine was measured daily. 'In-ICU AKI recurrence' was defined as a new spontaneous rise of ≥0.3 mg/dl within 48 h from the lowest serum creatinine after the previous AKI episode. RESULTS: Excluding 5 patients who suffered the AKI after the initial admission to ICU, 331 patients out of the 400 patients (82.8%) developed at least one AKI while they remained in the ICU. Among them, 79 (19.8%) developed ≥2 AKI episodes. Excluding 69 patients without AKI, in-hospital (adjusted HR = 2.48, 95% CI 1.47-4.19), 90-day (adjusted HR = 2.54, 95% CI 1.55-4.16) and end of follow-up (adjusted HR = 1.97, 95% CI 1.36-2.84) mortality rates were significantly higher in patients with recurrent AKI, independently of sex, age, mechanical ventilation necessity, APACHE score, baseline estimated glomerular filtration rate, complete recovery and KDIGO stage. CONCLUSIONS: AKI recurred in about 20% of ICU patients after a first episode of sepsis-related AKI. This recurrence increases the mortality rate independently of sepsis severity and of the KDIGO stage of the initial AKI episode. ICU physicians must be aware of the risks related to AKI recurrence while multiple episodes of AKI should be highlighted in electronic medical records and included in the variables of clinical risk scores.

Cost-effectiveness analysis of implementing an antimicrobial stewardship program in critical care units.

AIMS: To evaluate the cost-effectiveness of antimicrobial stewardship (AS) program implementation focused on critical care units based on assumptions for the Spanish setting. MATERIALS AND METHODS: A decision model comparing costs and outcomes of sepsis, community-acquired pneumonia, and nosocomial infections (including catheter-related bacteremia, urinary tract infection, and ventilator-associated pneumonia) in critical care units with or without an AS was designed. Model variables and costs, along with their distributions, were obtained from the literature. The study was performed from the Spanish National Health System (NHS) perspective, including only direct costs. The Incremental Cost-Effectiveness Ratio (ICER) was analysed regarding the ability of the program to reduce multi-drug resistant bacteria. Uncertainty in ICERs was evaluated with probabilistic sensitivity analyses. RESULTS: In the short-term, implementing an AS reduces the consumption of antimicrobials with a net benefit of €71,738. In the long-term, the maintenance of the program involves an additional cost to the system of €107,569. Cost per avoided resistance was €7,342, and cost-per-life-years gained (LYG) was €9,788. Results from the probabilistic sensitivity analysis showed that there was a more than 90% likelihood that an AS would be cost-effective at a level of €8,000 per LYG. LIMITATIONS: Wide variability of economic results obtained from the implementation of this type of AS program and short information on their impact on patient evolution and any resistance avoided. CONCLUSIONS: Implementing an AS focusing on critical care patients is a long-term cost-effective tool. Implementation costs are amortized by reducing antimicrobial consumption to prevent infection by multidrug-resistant pathogens.

Comparación de los sistemas de clasificación del fracaso renal agudo en la sepsis / A comparison of acute kidney injury classification systems in sepsis

Antecedentes: Desde 2004 se han propuesto diversos criterios para definir y estadiar el fracaso renal agudo (FRA), sin embargo, no se conoce cuál de ellos debe ser empleado cuando se desarrolla FRA en el contexto de la sepsis grave. Objetivo: Valorar la capacidad predictiva de mortalidad en una cohorte de pacientes con sepsis de los distintos métodos de clasificación del FRA. Métodos: Estudio prospectivo de los pacientes>18 años ingresados en la Unidad de Cuidados Intensivos (UCI) de nuestro hospital desde abril de 2008 hasta septiembre de 2010 con shock séptico. La creatinina plasmática se determinó diariamente en UCI. Los pacientes se clasificaron de forma retrospectiva según las clasificaciones RIFLE, AKIN, KDIGO y cinética de la creatinina (CK). Resultados: El porcentaje de pacientes que desarrolló FRA según cada clasificación fue: 74,3% RIFLE; 81,7% AKIN; 81,7% KDIGO y 77,5% CK. Cada estadio de FRA por RIFLE (OR 1,452; p=0,003), por AKIN (OR 1,349; p=0,028) y por KDIGO (OR 1,452; p=0,006) se relacionaba de forma independiente con la mortalidad intrahospitalaria, pero no por CK (OR 1,188; p=0,148). Conclusiones: Un porcentaje elevado de pacientes con sepsis grave desarrolla FRA que se puede clasificar según los distintos métodos propuestos. Los estadios de las clasificaciones RIFLE, AKIN y KDIGO se relacionan con un mayor riesgo de muerte intrahospitalaria. Por el contrario, la nueva definición de CK no se relaciona con una mayor mortalidad y no se debería usar en estos pacientes con sepsis grave sin confirmar su utilidad en estudios posteriores (AU)

Background: Since 2004, various criteria have been proposed to define and stage acute kidney injury (AKI). Nevertheless, fixed criteria for assessing severe sepsis-related AKI have not yet been established. Objectives: To assess the ability of the different AKI classification methods to predict mortality in a cohort of patients with sepsis. Methods: A prospective study of patients>18 years with septic shock admitted to the intensive care unit (ICU) of our hospital from April 2008 to September 2010 was conducted. Plasma creatinine levels were measured daily in the ICU. Patients were classified retrospectively according to RIFLE, AKIN, KDIGO and creatinine kinetics (CK) criteria. Results: The AKI rate according to the different criteria was 74.3% for RIFLE, 81.7% for AKIN, 81.7% for KDIGO and 77.5% for CK. AKI staging by RIFLE (OR 1.452, P=.003), AKIN (OR 1.349, P=.028) and KDIGO criteria (OR 1.452,P=.006), but not CK criteria (OR 1.188, P=.148) were independently related to in-hospital mortality. Conclusions: A high rate of patients with severe sepsis developed AKI, which can be classified according to different criteria. Each stage defined by RIFLE, AKIN and KDIGO related to a higher risk of in-hospital mortality. In contrast, the new CK criteria did not relate to higher mortality in patients with severe sepsis and this classification should not be used in these patients without further studies assessing its suitability (AU)

A comparison of acute kidney injury classification systems in sepsis. / Comparación de los sistemas de clasificación del fracaso renal agudo en la sepsis.

BACKGROUND: Since 2004, various criteria have been proposed to define and stage acute kidney injury (AKI). Nevertheless, fixed criteria for assessing severe sepsis-related AKI have not yet been established. OBJECTIVES: To assess the ability of the different AKI classification methods to predict mortality in a cohort of patients with sepsis. METHODS: A prospective study of patients>18 years with septic shock admitted to the intensive care unit (ICU) of our hospital from April 2008 to September 2010 was conducted. Plasma creatinine levels were measured daily in the ICU. Patients were classified retrospectively according to RIFLE, AKIN, KDIGO and creatinine kinetics (CK) criteria. RESULTS: The AKI rate according to the different criteria was 74.3% for RIFLE, 81.7% for AKIN, 81.7% for KDIGO and 77.5% for CK. AKI staging by RIFLE (OR 1.452, P=.003), AKIN (OR 1.349, P=.028) and KDIGO criteria (OR 1.452, P=.006), but not CK criteria (OR 1.188, P=.148) were independently related to in-hospital mortality. CONCLUSIONS: A high rate of patients with severe sepsis developed AKI, which can be classified according to different criteria. Each stage defined by RIFLE, AKIN and KDIGO related to a higher risk of in-hospital mortality. In contrast, the new CK criteria did not relate to higher mortality in patients with severe sepsis and this classification should not be used in these patients without further studies assessing its suitability.

Early phase detection of bile leak after hepatobiliary surgery: value of Gd-EOB-DTPA-enhanced MR cholangiography.

PURPOSE: To assess the value of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography for the detection of bile leaks after hepatobiliary surgery. METHODS: Twenty-three patients with symptoms suggestive of bile leak underwent conventional fat-suppressed T1- and T2-weighted MR cholangiography followed by Gd-EOB-DTPA-enhanced MR cholangiography using gradient-echo (GRE) T2-weighted sequences and fat-suppressed T1-weighted 3D gradient-echo sequences 20 min after an intravenous bolus of Gd-EOB-DTPA. The results of Gd-EOB-DTPA-enhanced MR cholangiography correlated with clinical findings, surgical repair, and the results of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. RESULTS: The results of Gd-EOB-DTPA-enhanced MR cholangiography were negative in 13 patients (cholecystectomy 5, liver transplantation 2, liver resection for focal lesions 2, cholangiocarcinoma 1, and partial hepatectomy after liver injury 1). In 10 patients in whom bile leaks were detected, this complication occurred after liver resection for focal lesions in 3, cholecystectomy in 4, liver transplantation in 2, and liver resection for intrahepatic cholangiocarcinoma in 1. The diagnostic accuracy of Gd-EOB-DTPA-enhanced MR for the detection or exclusion of bile leaks was 100%. CONCLUSIONS: Gd-EOB-DTPA-enhanced MR cholangiography is a highly reliable technique for the detection of bile leaks after hepatobiliary surgery and may avoid the use of other, potentially risky invasive diagnostic techniques.

Leiomioma gigante del espacio de Retzius / Giant leiomyoma in the Retzius space

No disponible

No disponible

Spinal muscular atrophy type I mimicking critical illness neuropathy in a paediatric intensive care neonate: electrophysiological features.

We report the case of a neonate with spinal muscular atrophy type I (SMA type I or Werdnig-Hoffman disease) who was initially misdiagnosis as having critical illness neuropathy. Electromyography (EMG) showed a moderate loss of voluntary and motor unit potentials of both neurogenic and myopathic appearance. Nerve conduction studies revealed the presence of a severe sensory-motor axonal neuropathy. Finally, a biopsy of quadriceps was compatible with the diagnosis of SMA type I. A genetic study confirmed the existence of a homozygous absence of exons 7 and 8 of the telomeric supervival motoneuron gene (SMN1 gene).

Necrotizing fasciitis after cesarean section.

We report a case of monomicrobial necrotizing fasciitis affecting a healthy woman after caesarean section. On day 1 post-partum she started taking a non-steroidal anti-inflammatory drug. The patient developed an acute fulminant infection and died from sepsis. The causative bacterium was Streptococcus pyogenes.