[Prone position in the third trimester of pregnancy during the COVID-19 era: a transdisciplinary approach.] / Decubito Prono En El Tercer Trimestre Del Embarazo Durante La Era Covid-19: Un Abordaje Transdisciplinar.

There is very limited evidence regarding the use of prone position as part of the treatment of severe ARDS in pregnant patients. Currently, recommendations for invasive ventilatory management in this population are very scarce and are based on the extrapolation of conclusions obtained in studies of non-pregnant patients. The available literature asserts that the anatomy and physiology of the pregnant woman undergoes complex adaptive changes that must be considered during invasive ventilatory support and prone position. With prone ventilation, the benefits obtained for the couple far outweigh the eventual risks. Adequate programming of the mechanical ventilator correlates with a clear and simple concept: individualization of support. In any case, the decision on the timing of termination of pregnancy should be based on adequate multidisciplinary clinical judgment and should be supported by strict monitoring of the product.

Impact of mobility restrictions on the dynamics of transmission of COVID-19 in Colombian cities.

BACKGROUND: Our aim was to study the association between case rates and reductions in urban mobility in state capitals of Colombia. METHODS: We designed an ecological time-series study to correlate the Colombian incidence rate with reductions in mobility trends of retail stores. RESULTS: The meta-analysis of ß coefficients describing the association between case rates and reductions in mobility trends of retail stores resulted in a mean estimate of 0.0637 (95% confidence interval 0.027 to 0.101; p<0.001) with nearly 100% heterogeneity. CONCLUSIONS: We recommend continuing to consider mobility restrictions when the number of cases starts to climb in each local jurisdiction.

Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study / Mortalidad hospitalaria y efecto de ajustar el cociente PaO2/FiO2 de acuerdo con la altitud por encima del nivel del mar en pacientes aclimatados que se someten a ventilación mecánica invasiva. Un estudio multicéntrico

OBJECTIVE: (I) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (II) Validate the traditional equation for adjusting PaO2/FiO2 according to the altitude. DESIGN: A prospective, observational, multicenter and international study conducted during August 2016. PATIENTS: Inclusion criteria: (I) age between 18 and 90 years old, (II) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (III) received invasive MV for at least 12 h. MATERIAL AND METHODS: All variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO2/FiO2 ratio was adjusted by the AASL according to: PaO2/FiO2 * (barometric pressure/760). Categorical variables were compared with χ2 and Cochran-Mantel-Haenszel test. Continuous variables with Mann-Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan-Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value < 0.05 was consider significant. RESULTS: 249 patients (< 1500 m n = 55; 1500 to < 2500 m n = 20; 2500 to < 3500 m n=155 and ≥ 3500 m n=19) were included. Adjusted and non-adjusted PaO2/FiO2 were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO2/FiO2 were identified. However, several correlations were appreciated only in patients situated < 1500 m or in > 1500 m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. AUROC: 0.72. CONCLUSION: In acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO2/FiO2 according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk

OBJETIVO: 1) Analizar el efecto de la altitud por encima del nivel del mar en la tasa de mortalidad de pacientes sometidos a ventilación mecánica invasiva, y 2) Validar la ecuación tradicional de ajuste de PaO2/FiO2, de acuerdo con la altitud. DISEÑO: Estudio internacional prospectivo, observacional y multicéntrico realizado durante agosto de 2016. PACIENTES: Criterios de inclusión: 1 Edad comprendida entre 18 y 90 años, 2 Haber sido ingresado en una unidad de cuidados intensivos (UCI) situada a la misma altitud por encima del nivel del mar (AASL) en la cual el paciente haya estado durante al menos los 40 días previos al estudio, y 3) Haber recibido ventilación mecánica (VM) durante al menos 12 h. MATERIALES Y MÉTODOS: Todas las variables se registraron el día de la intubación (día 0). El seguimiento se realizó hasta la muerte del paciente, el alta de la UCI o el día 28. El cociente PaO2/FiO2 se ajustó según los criterios de la AASL de acuerdo con: PaO2/FiO2 * (presión barométrica/760). Las variables categóricas se compararon mediante la prueba de χ2 y el test Cochran-Mantel-Haenszel, y las variables continuas con el test de Mann-Whitney. La correlación entre las variables continuas se analizó de forma gráfica y analítica. Para identificar los factores asociados a la mortalidad se elaboró un modelo de regresión logística. Se utilizó el método de Kaplan-Meier para estimar la probabilidad de supervivencia de acuerdo con la altitud. Un valor de p < 0,05 en la prueba bilateral se consideró como significativo. RESULTADOS: Se incluyeron 249 pacientes (< 1.500 m, n = 55; 1.500 a < 2.500 m, n = 20; 2.500 a < 3.500 m, n = 155 y ≥ 3.500 m, n = 19). El cociente PaO2/FiO2 mostró correlación con las variables graves tanto respiratorias como no respiratorias. No se registraron discordancias entre el cociente PaO2/FiO2 ajustado y sin ajustar. Únicamente se observaron diversas correlaciones entre los pacientes situados a < 1.500 m o a > 1.500 m. Setenta y nueve pacientes (32%) murieron durante la estancia en la UCI. La altitud sobre el nivel del mar no afectó a la curva de mortalidad. Las variables asociadas de forma independiente con la mortalidad fueron la presión positiva al final de la espiración (PEEP), la edad, la presión arterial sistólica y el recuento de plaquetas. El área bajo la curva ROC (AUROC) fue de 0,72. CONCLUSIÓN: En pacientes aclimatados sometidos a ventilación mecánica invasiva la ecuación tradicional para ajustar el cociente PaO2/FiO2, de acuerdo con la elevación sobre el nivel del mar parece inexacta. Por otro lado, la altitud por encima del nivel del mar no afecta al riego de mortalidad

Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study.

OBJECTIVE: (i) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (ii) Validate the traditional equation for adjusting PaO2/FiO2 according to the altitude. DESIGN: A prospective, observational, multicenter and international study conducted during August 2016. PATIENTS: Inclusion criteria: (i) age between 18 and 90 years old, (ii) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (iii) received invasive MV for at least 12h. MATERIAL AND METHODS: All variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO2/FiO2 ratio was adjusted by the AASL according to: PaO2/FiO2*(barometric pressure/760). Categorical variables were compared with χ2 and Cochran-Mantel-Haenszel test. Continuous variables with Mann-Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan-Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value <0.05 was consider significant. RESULTS: 249 patients (<1500m n=55; 1500 to <2500m n=20; 2500 to <3500m n=155 and ≥3500m n=19) were included. Adjusted and non-adjusted PaO2/FiO2 were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO2/FiO2 were identified. However, several correlations were appreciated only in patients situated <1500m or in >1500m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. AUROC: 0.72. CONCLUSION: In acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO2/FiO2 according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk.

Evidence-based guidelines for the use of tracheostomy in critically ill patients.

OBJECTIVES: To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. CONCLUSIONS: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Performance of the Obstetric Early Warning Score in critically ill patients for the prediction of maternal death.

BACKGROUND: Every day, about 830 women die worldwide from preventable causes related to pregnancy and childbirth. Obstetric early warning scores have been proposed as a potential tool to reduce maternal morbidity and mortality, based on the identification of predetermined abnormal values in the vital signs or laboratory parameters, to generate a rapid and effective medical response. Several early warning scores have been developed for obstetrical patients, but the majority are the result of a clinical consensus rather than statistical analyses of clinical outcome measures (ie, maternal deaths). In 2013, the Intensive Care National Audit and Research Center Case Mix Program reported the first statistically validated early warning scoring system for pregnant women. OBJECTIVE: We sought to assess the performance of the Intensive Care National Audit and Research Center Obstetric Early Warning Score in predicting death among pregnant women who required admission to the intensive care unit. STUDY DESIGN: This retrospective cohort study included pregnant women admitted to the intensive care unit at a tertiary referral center from January 2006 through December 2011 in Colombia, a developing country, with direct and indirect obstetric-related conditions. The Obstetric Early Warning Score was calculated based on data collected during the first 24 hours of intensive care unit admission. The Obstetric Early Warning Score is calculated based on values of the following variables: systolic and diastolic blood pressure, respiratory rate, heart rate, fraction of inspired oxygen (FiO2) required to maintain an oxygen saturation ≥96%, temperature, and level of consciousness. The performance of the Obstetric Early Warning Score was evaluated using the area under the receiver operator characteristic curve. Outcomes selected were: maternal death, need for mechanical ventilation, and/or vasoactive support. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. RESULTS: During the study period, 50,897 births were recorded. There were 724 obstetric admissions to critical care, for an intensive care unit admission rate of 14.22 per 1000 deliveries. A total of 702 women were included in the study, with 29 (4.1%) maternal deaths, and a mortality ratio of 56.98 deaths per 100,000 live births. The most frequent causes of admission were direct, obstetric-related conditions (n = 534; 76.1%). The Obstetric Early Warning Score value was significantly higher in nonsurvivors than in survivors [12 (interquartile range 10-13) vs 7 (interquartile range 4-9); P < .001]. Peripartum women with normal values of Obstetric Early Warning Score had 0% mortality rate, while those with high Obstetric Early Warning Score values (>6) had a mortality rate of 6.3%. The area under the receiver operator characteristic curve of the Obstetric Early Warning Score in discrimination of maternal death was 0.84 (95% confidence interval, 0.75-0.92). The overall predictive value of the Obstetric Early Warning Score was better when the main cause of admission was directly related to pregnancy or the postpartum state. The area under the receiver operator characteristic curve of the score in conditions directly related to pregnancy and postpartum was 0.87 (95% confidence interval, 0.79-0.95), while in indirectly related conditions the area under the receiver operator characteristic curve was 0.77 (95% confidence interval, 0.58-0.96). CONCLUSION: Although there are opportunities for improvement, Obstetric Early Warning Score obtained upon admission to the intensive care unit can predict survival in conditions directly related to pregnancy and postpartum. The use of early warning scores in obstetrics may be a highly useful approach in the early identification of women at an increased risk of dying.

Maternal mortality secondary to acute respiratory failure in Colombia: a population-based analysis.

PURPOSE: To estimate the mortality rate and trends of respiratory failure in the pregnant and postpartum population of Colombia. METHODS: A retrospective analysis of the national registry of mortality in Colombia was performed from 1998 to 2009. Maternal death was defined as death that occurred during pregnancy or up to 42 days postpartum. Two independent investigators reviewed maternal deaths to determine deaths caused by respiratory failure. Inter-rater agreement was assessed by kappa correlation coefficient. Causes of respiratory failure were identified according to the International Classification of Diseases (ICD-10). RESULTS: During the study period, 8,637,486 live births were reported with 6,676 maternal deaths for an overall maternal mortality rate (MMR) of 82.9 per 100,000 live births. Of these, a total of 835 cases were related to respiratory failure, with a specific MMR of 9.69 per 100,000 live births. The main causes of maternal deaths due to respiratory failure included pulmonary sepsis (284 cases, or 3.58 per 100,000 live births), pulmonary embolism (119 cases or 1.50 per 100,000 live births), and preeclampsia-related pulmonary edema (112 cases or 1.41 per 100,000 live births). All-cause maternal mortality ratio decreased yearly from 1998 to 2009 by -3.76% (95% CI -4.83 to -2.67), while the trend of mortality secondary to respiratory failure remained stable over time (P = 0.449). CONCLUSIONS: Respiratory failure is an important cause of mortality in the obstetric population in Colombia, with pulmonary sepsis as the lead cause of respiratory failure among maternal deaths. While overall maternal mortality rates have decreased in the last decade, respiratory failure-related deaths have remained stable over time.

Epidemiology of sepsis in Colombian intensive care units.

INTRODUCTION: Currently, there is not enough data available concerning sepsis in developing countries, especially in Latin America. OBJECTIVE: We developed a study aimed at determining the frequency, clinical and epidemiological characteristics, and the consequences of sepsis in patients requiring admission to intensive care units in Colombia. MATERIALS AND METHODS: This was a secondary analysis of a prospective cohort study carried out over a six-month period, from September 1, 2007, to February 28, 2008, in ten medical/surgical intensive care units in four Colombian cities. Patients were considered eligible if they had a probable or confirmed diagnosis of infection according to medical records. We recorded demographic characteristics, first admission diagnosis and co-morbidities, clinical status, and sepsis, severe sepsis or septic shock. RESULTS: During the study period, 826 patients were admitted to the intensive care units. From these patients, 421 (51%) developed sepsis in the community, 361 (44%) in the ICU, and 44 (5%) during hospitalization in the general ward. Two hundred and fifty three patients (30.6%) had involvement of one organ system: 20% had respiratory involvement, followed by kidney and central nervous system involvement with 3.4% and 2.7%, respectively. CONCLUSIONS: In our cohort of septic patients, the prevalence of sepsis treated in ICU is similar to that reported in other studies, as well as the overall mortality.

Epidemiology of sepsis in Colombian intensive care units / Epidemiología de la sepsis en unidades de cuidado intensivo en Colombia

Introduction: Currently, there is not enough data available concerning sepsis in developing countries, especially in Latin America. Objective: We developed a study aimed at determining the frequency, clinical and epidemiological characteristics, and the consequences of sepsis in patients requiring admission to intensive care units in Colombia. Materials and methods: This was a secondary analysis of a prospective cohort study carried out over a six-month period, from September 1, 2007, to February 28, 2008, in ten medical/surgical intensive care units in four Colombian cities. Patients were considered eligible if they had a probable or confirmed diagnosis of infection according to medical records. We recorded demographic characteristics, first admission diagnosis and co-morbidities, clinical status, and sepsis, severe sepsis or septic shock. Results: During the study period, 826 patients were admitted to the intensive care units. From these patients, 421 (51%) developed sepsis in the community, 361 (44%) in the ICU, and 44 (5%) during hospitalization in the general ward. Two hundred and fifty three patients (30.6%) had involvement of one organ system: 20% had respiratory involvement, followed by kidney and central nervous system involvement with 3.4% and 2.7%, respectively. Conclusions: In our cohort of septic patients, the prevalence of sepsis treated in ICU is similar to that reported in other studies, as well as the overall mortality.

Introducción. Actualmente no se cuenta con muchos datos disponibles sobre la sepsis en los países en desarrollo y especialmente en América Latina. Objetivo. Este estudio tuvo como objetivo determinar la frecuencia, las características clínicas y epidemiológicas y las consecuencias de la sepsis en una población de pacientes que requirieron ingreso en algunas unidades colombianas de cuidados intensivos. Materiales y métodos. Este fue un análisis secundario de un estudio prospectivo realizado en un período de seis meses contados a partir del 1° de septiembre de 2007 hasta el 28 de febrero del 2008 en diez unidades médico-quirúrgicas de cuidados intensivos de cuatro ciudades de Colombia. Los pacientes se consideraron elegibles si tenían un diagnóstico probable o confirmado de infección según los registros médicos. Se registraron las características demográficas, los diagnósticos de primer ingreso y las enfermedades concomitantes, el estado clínico y la sepsis, sepsis grave o choque séptico. Resultados. Durante el período de estudio, 826 pacientes fueron ingresados en las unidades de cuidados intensivos seleccionadas para el estudio. De estos pacientes, 421 (51 %) desarrollaron sepsis en la comunidad, 361 (44 %) en la unidad de cuidados intensivos y 44 (5 %) durante la hospitalización en la sala general; 253 pacientes (30,6 %) presentaron afectación de un órgano del sistema: 20 % tuvo problemas respiratorios, seguido por problemas en los riñones y el sistema nervioso central con 3,4 % y 2,7 %, respectivamente. Conclusiones. En la muestra de pacientes sépticos, la prevalencia de la sepsis, así como de la mortalidad global, en los pacientes tratados en la unidad de cuidados intensivos fue similar a la reportada en otros estudios.

Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities.

PURPOSE: Cities are expanding rapidly in middle-income countries, but their supply of acute care services is unknown. We measured acute care services supply in seven cities of diverse economic background. METHODS: In a cross-sectional study, we compared cities from two high-income (Boston, USA and Paris, France), three upper-middle-income (Bogota, Colombia; Recife, Brazil; and Liaocheng, China), and two lower-middle-income (Chennai, India and Kumasi, Ghana) countries. We collected standardized data on hospital beds, intensive care unit beds, and ambulances. Where possible, information was collected from local authorities. We expressed results per population (from United Nations) and per acute illness deaths (from Global Burden of Disease project). RESULTS: Supply of hospital beds where intravenous fluids could be delivered varied fourfold from 72.4/100,000 population in Kumasi to 241.5/100,000 in Boston. Intensive care unit (ICU) bed supply varied more than 45-fold from 0.4/100,000 population in Kumasi to 18.8/100,000 in Boston. Ambulance supply varied more than 70-fold. The variation widened when supply was estimated relative to disease burden (e.g., ICU beds varied more than 65-fold from 0.06/100 deaths due to acute illnesses in Kumasi to 4.11/100 in Bogota; ambulance services varied more than 100-fold). Hospital bed per disease burden was associated with gross domestic product (GDP) (R (2) = 0.88, p = 0.01), but ICU supply was not (R (2) = 0.33, p = 0.18). No city provided all requested data, and only two had ICU data. CONCLUSIONS: Urban acute care services vary substantially across economic regions, only partially due to differences in GDP. Cities were poor sources of information, which may hinder their future planning.

Lactato sérico en urgencias como factor pronóstico en pacientes con sepsis sin hipotensión / Serum lactate in the emergency department as a prognostic factor in patients with sepsis without hypotension

Fundamento y objetivo: La relación del lactato y la mortalidad en sepsis no ha sido explorada adecuadamente en el paciente normotenso. Nuestro objetivo fue determinar la utilidad del lactato como factor pronóstico de mortalidad a los 28 días en pacientes admitidos en el Servicio de Urgencias con diagnóstico clínico de sepsis y sin shock séptico. Pacientes y método: Análisis secundario del estudio La epidemiología de la sepsis en Colombia, una cohorte prospectiva de pacientes en 10 hospitales generales de 4 ciudades de Colombia. Se incluyeron en este análisis los pacientes sin hipotensión, con disponibilidad de lactato y admitidos con infecciones adquiridas en la comunidad confirmadas con los criterios de los Centers for Disease Control and Prevention. Se realizó una regresión logística controlando para la edad, el sexo, las comorbilidades y la puntuación de gravedad. Resultados: Se incluyeron 961 pacientes, con edad media (DE) de 57,2 (21,0) años, el 54,2% eran mujeres, la puntuación SOFA (Sequential Organ Failure Assessment) promedio fue de 3,0 (2,3) y el APACHE (Acute Physiologic and Chronic Health Evaluation) de 11,1 (6,4). Se observó un buen ajuste al modelo lineal entre el lactato y el riesgo de muerte, y al ajustar por los factores de confusión el lactato se asoció de manera significativa con la mortalidad (odds ratio 1,16, intervalo de confianza del 95% 1,02-1,33). Conclusión: El valor de lactato se asocia de forma independiente y significativa con la mortalidad a los 28 días entre los pacientes con infección que se presentan en el Departamento de Urgencias sin hipotensión. Además, la mortalidad se incrementa de manera lineal con los valores de lactato sérico a partir de cualquier valor detectable (AU)

Background and objective: The relationship between lactate and mortality in patients without hypotension has not been appropriately explored. Our aim was to determine the usefulness of serum lactate as a prognostic factor of 28-day mortality in patients admitted to the Emergency Department with clinical diagnosis of sepsis without septic shock. Patients and methods: We performed a secondary analysis of the study The epidemiology of sepsis in Colombia, a prospective cohort of patients from 10 general hospitals in 4 Colombian cities. We analyzed patients without hypotension with serum lactate available and admitted with community-acquired infections, which were confirmed according to the Centers for Disease Control and Prevention CDC criteria. A logistical regression was performed adjusting for age, sex, comorbidities and severity scores. Results: We included 961 patients aged 57.2 ± 21.0 years, 54.2% were females, mean SOFA score was 3.0 ± 2.3 and APACHE score was 11.1 ± 6.4. We observed a linear relationship between serum lactate and the odds of death, and after adjustment there was a significant and independent association between lactate and mortality (odds ratio 1,16, 95% confidence interval 1.02-1.33). Conclusion: Serum lactate is independently and significantly associated with 28-day mortality among patients with infection who present to the Emergency Department without hypotension. Besides, mortality increases in a linear way with serum lactate from any detectable value (AU)

Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals.

BACKGROUND: Sepsis has several clinical stages, and mortality rates are different for each stage. Our goal was to establish the evolution and the determinants of the progression of clinical stages, from infection to septic shock, over the first week, as well as their relationship to 7-day and 28-day mortality. METHODS: This is a secondary analysis of a multicenter cohort of inpatients hospitalized in general wards or intensive care units (ICUs). The general estimating equations (GEE) model was used to estimate the risk of progression and the determinants of stages of infection over the first week. Cox regression with time-dependent covariates and fixed covariates was used to determine the factors related with 7-day and 28-day mortality, respectively. RESULTS: In 2681 patients we show that progression to severe sepsis and septic shock increases with intraabdominal and respiratory sources of infection [OR = 1,32; 95%IC = 1,20-1,46 and OR = 1.21, 95%CI = 1,11-1,33 respectively], as well as according to Acute Physiology and Chronic Health Evaluation II (APACHE II) [OR = 1,03; 95%CI = 1,02-1,03] and Sequential Organ Failure Assessment (SOFA) [OR = 1,16; 95%CI = 1,14-1,17] scores. The variables related with first-week mortality were progression to severe sepsis [HR = 2,13; 95%CI = 1,13-4,03] and septic shock [HR = 3,00; 95%CI = 1,50-5.98], respiratory source of infection [HR = 1,76; 95%IC = 1,12-2,77], APACHE II [HR = 1,07; 95% CI = 1,04-1,10] and SOFA [HR = 1,09; 95%IC = 1,04-1,15] scores. CONCLUSIONS: Intraabdominal and respiratory sources of infection, independently of SOFA and APACHE II scores, increase the risk of clinical progression to more severe stages of sepsis; and these factors, together with progression of the infection itself, are the main determinants of 7-day and 28-day mortality.

[Serum lactate in the emergency department as a prognostic factor in patients with sepsis without hypotension]. / Lactato sérico en urgencias como factor pronóstico en pacientes con sepsis sin hipotensión.

BACKGROUND AND OBJECTIVE: The relationship between lactate and mortality in patients without hypotension has not been appropriately explored. Our aim was to determine the usefulness of serum lactate as a prognostic factor of 28-day mortality in patients admitted to the Emergency Department with clinical diagnosis of sepsis without septic shock. PATIENTS AND METHODS: We performed a secondary analysis of the study The epidemiology of sepsis in Colombia, a prospective cohort of patients from 10 general hospitals in 4 Colombian cities. We analyzed patients without hypotension with serum lactate available and admitted with community-acquired infections, which were confirmed according to the Centers for Disease Control and Prevention CDC criteria. A logistical regression was performed adjusting for age, sex, comorbidities and severity scores. RESULTS: We included 961 patients aged 57.2 ± 21.0 years, 54.2% were females, mean SOFA score was 3.0 ± 2.3 and APACHE score was 11.1±6.4. We observed a linear relationship between serum lactate and the odds of death, and after adjustment there was a significant and independent association between lactate and mortality (odds ratio 1,16, 95% confidence interval 1.02-1.33). CONCLUSION: Serum lactate is independently and significantly associated with 28-day mortality among patients with infection who present to the Emergency Department without hypotension. Besides, mortality increases in a linear way with serum lactate from any detectable value.

Biomarcadores cardíacos: presente y futuro / Cardiac biomarkers: present and future

En la actualidad, las enfermedades cardiovasculares se consideran la pandemia más significativa del siglo XXI. Dentro de ellas, la enfermedad coronaria es la más prevalente y la que más morbi-mortalidad genera; en el caso particular de Colombia, es la principal causa de muerte en individuos mayores de 45 años. La característica silenciosa de esta enfermedad ha impulsado la investigación de moléculas que permitan su diagnóstico precoz y sirvan como predictores pronóstico tanto en la fase crónica como en la aguda. Fruto de estas investigaciones, en los últimos treinta años se ha producido un avance importante en el desarrollo de biomarcadores cardiacos. Entre ellos están los recién desarrollados ensayos de troponinas ultrasensibles para diagnóstico temprano, la medición de la albúmina modificada por isquemia que cuenta con alto valor predictivo negativo para la detección de isquemia miocárdica, el ligando de CD40 soluble para la clasificación e individualización del tratamiento, la utilidad de la proteína C reactiva como marcador de riesgo de enfermedad coronaria y las diversas técnicas de alto rendimiento como la proteómica, que permite la detección de múltiples biomarcadores potenciales. A pesar de ello, aún no se dispone de evidencia suficiente para sustituir los marcadores que recomiendan las asociaciones científicas por los nuevos marcadores que se han ido desarrollando, y continúa el debate sobre qué combinación utilizar para alcanzar mayor rendimiento diagnóstico, pronostico y terapéutico. A continuación se revisan los avances actuales en biomarcadores cardiacos y su potencial integración a la práctica clínica habitual.

En la actualidad, las enfermedades cardiovasculares se consideran la pandemia más significativa del siglo XXI. Dentro de ellas, la enfermedad coronaria es la más prevalente y la que más morbi-mortalidad genera; en el caso particular de Colombia, es la principal causa de muerte en individuos mayores de 45 años. La característica silenciosa de esta enfermedad ha impulsado la investigación de moléculas que permitan su diagnóstico precoz y sirvan como predictores pronóstico tanto en la fase crónica como en la aguda. Fruto de estas investigaciones, en los últimos treinta años se ha producido un avance importante en el desarrollo de biomarcadores cardiacos. Entre ellos están los recién desarrollados ensayos de troponinas ultrasensibles para diagnóstico temprano, la medición de la albúmina modificada por isquemia que cuenta con alto valor predictivo negativo para la detección de isquemia miocárdica, el ligando de CD40 soluble para la clasificación e individualización del tratamiento, la utilidad de la proteína C reactiva como marcador de riesgo de enfermedad coronaria y las diversas técnicas de alto rendimiento como la proteómica, que permite la detección de múltiples biomarcadores potenciales. A pesar de ello, aún no se dispone de evidencia suficiente para sustituir los marcadores que recomiendan las asociaciones científicas por los nuevos marcadores que se han ido desarrollando, y continúa el debate sobre qué combinación utilizar para alcanzar mayor rendimiento diagnóstico, pronostico y terapéutico. A continuación se revisan los avances actuales en biomarcadores cardiacos y su potencial integración a la práctica clínica habitual.

Disección aórtica aguda tipo A, una enfermedad catastrófica asociada al embarazo / Type A acute aortic dissection: a catastrophic event associated with pregnancy

Objetivo. Describir 2 casos mortales de disección aórtica aguda tipo A asociada al embarazo. Métodos. Se revisan las historias clínicas y las necropsias de las pacientes, luego se explican algunos mecanismos que relacionan a esta entidad con el embarazo. Resultados. Ambas defunciones se dieron en mujeres menores de 35 años, al final de la gestación. Un caso, asociado con una coartación aórtica y aorta bicúspide, la otra paciente sin factores de riesgo. Conclusión. Algunos cambios hemodinámicos del tercer trimestre del embarazo podrían estar involucrados con la aparición de esta enfermedad; considerar su diagnóstico es vital para evitar su gran mortalidad (AU)

Objective. To describe two fatal cases of type A acute aortic dissection associated with pregnancy. Methods. We reviewed the medical records and autopsies of patients, and then identified some mechanisms linking this entity to pregnancy. Results. Both deaths occurred in women aged less than 35 years at the end of gestation. One patient had aortic coarctation and bicuspid aortic valve, while the other had no risk factors. Conclusion. Hemodynamic changes in the third trimester of pregnancy may be involved in the onset of this entity. Rapid diagnosis is essential to prevent its high associated mortality (AU)

Variables asociadas a mortalidad por infarto del miocardio en adultos mayores de 75 años en Cartagena de Indias, Colombia: un estudio piloto / Variables associated to mortality for myocardial infarction in adults over 75 years in Cartagena de Indias, Colombia: a pilot study

Introducción: el incremento de la población de adultos mayores hace más frecuente la observación de infarto agudo del miocardio en personas de 75 años o más. Aproximadamente 30% de los casos de infarto agudo del miocardio se presentan en estas edades. Sin embargo, no se han explorado las variables relacionadas con mortalidad hospitalaria en Cartagena de Indias, Colombia. Objetivo: explorar algunas variables asociadas con mortalidad por infarto del miocardio en adultos hospitalizados mayores de 75 años, en Cartagena de Indias, Colombia. Método: se realizó un estudio analítico observacional transversal. Se revisaron historias clínicas de pacientes hospitalizados por infarto agudo del miocardio durante 2008 y 2009. Se realizó regresión logística para ajustar las asociaciones. Resultados: participaron ochenta personas adultas con edades entre 75 y 94 años, media para la edad de 80,7 años; 50% mujeres. Durante la hospitalización murieron veinte pacientes (25,0%). La mortalidad se asoció de manera significativa con Killip III-IV (OR=5,93; IC95% 1,80-19,53). Conclusiones: presentar Killip III-IV al ingreso a causa de un infarto agudo del miocardio, se asocia con mayor mortalidad en adultos mayores de 75 años. Se requieren estudios con mayor muestra de participantes para corroborar los hallazgos.

Introduction: the increment of elderly population enables the observation of myocardial infarction in people aged 75 years or more. Approximately 30% of the cases of acute myocardial infarction are present at these ages. However, the variables related to hospital mortality in Cartagena de Indias, Colombia, have not been explored. Objective: explore some variables associated to mortality for myocardial infarction in hospitalized adults over 75 in Cartagena de Indias, Colombia. Method: we performed an analytical cross-sectional observational study. The clinical records of patients hospitalized for acute myocardial infarction during 2008 and 2009 were reviewed. We made a logistic regression in order to adjust the associations. Results: eighty adults with ages between 75 and 94 years participated in the study. Mean age was 80,7 ears; 50% were women. During the hospitalization, twenty patients (25,0%) died. Mortality was significantly associated to Killip III-IV (OR=5,93; IC 95% 1,80-19,53). Conclusions: the presence of Killip III-IV on admission due to acute myocardial infarction is associated to higher mortality in adults over 75 years. Studies with a higher number of participants are required to corroborate these findings.

The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals.

OBJECTIVE: Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital-based population in Colombia. DESIGN: Prospective cohort. SETTING: Ten general hospitals in the four main cities of Colombia. PATIENTS: Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (SD = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5-19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (SD = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (SD = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%. CONCLUSIONS: In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score.

Ventilación no invasiva en las unidades de cuidado intensivo en Colombia: una práctica rutinaria / Non-invasive ventilation at intensive care units in Colombia: a routine practice

Introducción: la ventilación mecánica no invasiva (VNI) ha tenido notables avances en cuanto a técnica y aplicaciones en los últimos 10 años. En Colombia, la utilización de la VNI en UCI ha sido en apariencia limitada y su impacto desconocido. Objetivos: describir la situación actual de la VNI en las unidades de cuidado intensivo (UCI) en Colombia en cuanto a conocimientos, actitudes, percepciones y prácticas. Diseño: estudio observacional descriptivo de corte transversal. Materiales y métodos: se conformó un grupo focal y se hicieron entrevistas semiestructuradas a pacientes, para definir los dominios que orientaron la encuesta. Se efectuó un estudio piloto aplicado por conveniencia a cinco médicos que han trabajado en UCI. Se incluyeron unidades de cuidado intensivo adulto colombianas. Todos los directores de UCI, recibieron por medio de correo información acerca del estudio y una invitación para programar una cita telefónica. Resultados: se registraron 136 UCI en el país, 113 (83%) contestaron, 70% privadas; en Bogotá 30%, región caribe 21%, centro del país 17% y Medellín 12%; la mayor cantidad de UCI (51%) tenían entre 7-12 camas. Conocimientos: la distribución de respuestas correctas fue la siguiente: Conocimientos en indicación en EPOC 85%, otras indicaciones 43%. No hay diferencias importantes en el conocimiento al hacer un análisis por tamano de las unidades (p > 0,05), pero la diferencia por regiones es significativa (p < 0,001) entre la de mayor y menor porcentaje de respuestas correctas. Prácticas: se utilizó VNI en el 80% de las UCI de Colombia. En Medellín la usaron en 100% de las unidades y la menor utilización se describió en la región central del país con 63%. En los 90 días anteriores a la encuesta los entrevistados usaron ventilación mecánica en un promedio de 89 pacientes, de los cuales 12 (13%) se trataron con VNI. El 33% de ellos fueron eventualmente intubados. Entre el grupo de UCI que no utilizaron VNI, la razón que se argumentó para no utilizarla fue la falta de recursos (80%) y las razones de no conocimientos, falta de confianza y de no tenerla en cuenta sumó 20%. El 76% de la UCI en Colombia no tenían ventiladores específicos para VNI y solo la mitad tenían máscaras específicas. No hubo diferencia de recursos entre UCI privadas y públicas. Actitudes y percepciones: entre los directores la técnica genera confianza y la sensación de ser importante para el manejo. Conceptuaron que debería utilizarse más de lo que ha sido usada hasta hoy. Percibían que se complicaban menos que los que se intubaban. Opinaron que era menos costosa su utilización que la ventilación invasiva, en personal, equipos y accesorios. Los entrevistados percibían que el paciente y su familia aceptaban mejor la ventilación no invasiva que la invasiva. Conclusiones: el estudio fue representativo por haber encuestado más del 80% de las UCI de adultos del país. Existe desconocimiento entre los directores de UCI acerca de la VNI en paciente crítico, teniendo conocimiento satisfactorio en la indicación en EPOC. El uso de VNI en las UCI de Colombia fue elevado y pareció evitar un alto número de intubaciones, a pesar de no tener los recursos adecuados. La percepción acerca de la técnica fue buena.

Delirium epidemiology in critical care (DECCA): an international study.

INTRODUCTION: Delirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU. METHODS: A 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain. RESULTS: In total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%). CONCLUSIONS: In this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

Curso clínico y supervivencia en embolia pulmonar. Resultados del registro multicéntrico colombiano (EMEPCO) / Clinical course and survival in pulmonary embolism. Results of the Colombian multicentric registry (EMEPCO)

Introducción: la embolia pulmonar (EP) se asocia con morbilidad y mortalidad sustanciales, sin embargo existe muy poca información proveniente de países latinoamericanos. Los objetivos de este estudio fueron el describir el curso clínico y la supervivencia de una cohorte con EP, e identificar factores asociados con la mortalidad hospitalaria.Pacientes y método: estudio de cohorte en instituciones de cuatro ciudades colombianas. Pacientes adultos con EP por criterios previamente establecidos, fueron invitados a participar. La información sobre factores de riesgo, cuadro clínico, exámenes, tratamientos, y estado vital al alta hospitalaria y hasta por 12 meses, fue recogida sistemáticamente por personal entrenado.Resultados: el total de pacientes incluidos fue 251, con edad promedio de 65 años (DE 18); 66 porciento fueron mujeres. La frecuencia de trombo-profilaxis fue 22 porciento. La mortalidad hospitalaria fue 14.8 porciento (IC95 porciento: 11 – 19 porciento). Factores asociados con mortalidad hospitalaria incluyeron hipotensión (RR: 2.57; IC95 porciento: 1.4 – 4.73) y fractura de cadera (RR: 2.55; IC95 porciento: 1.34-4.83). La supervivencia a las 52 semanas poshospitalización fue 85 porciento (IC95 porciento: 79-90 porciento).Conclusiones: en esta cohorte colombiana, la EP estuvo asociada con mortalidad sustancial temprana y tardía. La mayor mortalidad en pacientes con fractura de cadera refuerza la necesidad de uso rutinario de estrategias de tromboprofilaxis efectivas y seguras.