Clinical factors associated with inappropriate prophylaxis of venous thromboembolic disease in critically ill patients. A single day cross-sectional study.

PURPOSE: A poor implementation of VTE prophylactic measures recommended for critically ill patients has been observed in several epidemiological studies. The clinical factors associated with this have not been clearly established. The objective of our study was to identify which factors could be related to the inappropriate use of VTE prophylaxis. METHODS: Analytic epidemiological study based on different aspects of VTE prophylaxis performed on Spanish ICU patients. A multiple logistic regression analysis was conducted to identify the risk factors associated with inappropriate prophylaxis, according to the American College of Chest Physicians 2012 guidelines. RESULTS: We enrolled 777 patients. On admission, 62% presented medical, 30% surgical and 8% major trauma pathology. Of all patients, 41% were receiving an inappropriate prophylaxis, including 19% which did not receive any prophylaxis. The presence of a contraindication for pharmacological prophylaxis (OR 3.91, 95% CI 2.50-6.10) and non-medical pathology at ICU admission (OR 11.09; 95% CI 7.63-16.12) were associated with inappropriate prophylaxis. In contrast, mechanical ventilation (OR 0.70, 95% CI 0.45-0.98), bed rest>48h (OR 0.61, 95% CI 0.49-0.98), the use of a protocol for VTE prophylaxis (OR 0.66, 95% CI 0.45-0.98) and a VTE risk scoring system (OR 0.49, 95% CI 0.24-0.98) were associated with adequate prophylaxis. CONCLUSIONS: Our study highlighted a poor compliance with the VTE prophylaxis recommendations proposed for critical patients. The implementation of specific protocols for prophylaxis that include a correct evaluation according to VTE and haemorrhage risk, would allow for optimisation of mechanical and combined prophylaxis, improving adherence to the clinical practice guidelines.

Emergence of linezolid-resistant coagulase-negative staphylococci in an intensive care unit.

BACKGROUND: The aim of this study was to report the emergence of linezolid-resistant coagulase-negative staphylococci (CoNS) in an intensive care unit. METHODS: An observational study was conducted in critically ill patients with colonization or infection by linezolid-resistant CoNS between January 2010 and December 2014. We analyzed the epidemiological and clinical features, and the mechanism of resistance to linezolid. We also evaluated the association between the incidence of linezolid-resistant CoNS strains and the consumption of linezolid in the study period. RESULTS: During the study period 49 patients had a linezolid-resistant CoNS strain isolated from clinical samples (blood in 42 cases, urine in 6, peritoneal fluid in 1). Molecular study showed a combination of mechanisms of resistance. Most patients were critically ill (APACHE II score = 21.9 ± 8.3) and nearly all had undergone surgery and invasive procedures, and had prior exposure to antibiotics. Linezolid-resistant CoNS were considered to be contaminants in 42 patients and associated with infection in 7 patients, comprising bacteremia and septic shock in most of them. They were successfully treated with glycopeptides or daptomycin. A modest significant correlation was observed between the decrease in linezolid consumption and the lower incidence of resistant isolates. CONCLUSIONS: Linezolid-resistant CoNS had emerged in critically ill patients with severe underlying diseases and prior antibiotic exposure. Most isolates represented colonization; however, linezolid-resistant CoNS can produce serious infections in critically ill patients. Glycopeptides and daptomycin seem to provide useful alternatives for therapy of these infections. A relationship was found between linezolid consumption and the incidence of linezolid-resistant CoNS strains.

PROF-ETEV study: prophylaxis of venous thromboembolic disease in critical care units in Spain.

PURPOSE: Venous thromboembolic disease (VTE) in critically ill patients has a high incidence despite prophylactic measures. This fact could be related to an inappropriate use of these measures due to the absence of specific VTE risk scores. To assess the current situation in Spain, we have performed a cross-sectional study, analyzing if the prophylactic measures were appropriate to the patients' VTE risk. METHODS: Through an electronic questionnaire, we carried out a single day point prevalence study on the VTE prophylactic measures used in several critical care units in Spain. We performed a risk stratification for VTE in three groups: low, moderate-high, and very high risk. The American College of Chest Physicians guidelines were used to determine if the patients were receiving the recommended prophylaxis. RESULTS: A total of 777 patients were included; 62% medical, 30% surgical, and 7% major trauma patients. The median number of the risk factors for VTE was four. According to the proposed VTE risk score, only 2% of the patients were at low risk, whereas 83% were at very high risk. Sixty-three percent of patients received pharmacological prophylaxis, 12% mechanical prophylaxis, 6% combined prophylaxis, and 19% did not receive any prophylactic measure. According to criteria suggested by the guidelines, 23% of medical, 71% of surgical, and 70% of major trauma patients received an inappropriate prophylaxis. CONCLUSIONS: Most critically ill patients are at high or very high risk of VTE, but there is a low rate of appropriate prophylaxis. The efforts to improve the identification of patients at risk, and the implementation of appropriate prevention protocols should be enhanced.

Temperature curve complexity predicts survival in critically ill patients.

RATIONALE: Temperature curve complexity is inversely related to clinical status in critically ill patients. OBJECTIVE: To study if temperature curve complexity analysis predicts clinical outcome and how this test compares to other well-established conventional measures. METHODS: Temperature was continuously recorded in 50 patients with multiple organ failure. Time-series complexity was analyzed using hourly approximate entropy (ApEn) and detrended fluctuation analysis (DFA) values. Sequential Organ Failure Assessment (SOFA) score was obtained every other day, and correlation between complexity and SOFA values was evaluated. Differences in complexity between nonsurviving and surviving patients were likewise analyzed. Logistic regression models were calculated to predict outcome, and receiver operating characteristic (ROC) curves were plotted to compare the predictive power of complexity values versus SOFA. MEASUREMENTS AND RESULTS: There was good correlation between complexity results and clinical scores for each patient. Nonsurvivors exhibited lower complexity values than survivors (minimum ApEn = 0.230 vs. 0.378; maximum DFA = 1.636 vs. 1.507; mean ApEn = 0.459 vs. 0.596; mean DFA = 1.376 vs. 1.288; p < 0.001 for all comparisons). In the logistic regression model, a change of 0.1 in the minimum complexity resulted in severe increases in the odds ratio of dying (7.6-fold for ApEn, 5.4-fold for DFA). In terms of predicting outcome, there were no significant differences in the areas under the ROC curves for complexity values versus SOFA scores. CONCLUSIONS: Low levels of complexity in the temperature curve are indicators of poor prognosis in patients with multiple organ failure. The predictive ability of temperature curve complexity is similar to that of the SOFA score.

Clinical implications of temperature curve complexity in critically ill patients.

OBJECTIVE: In certain physiologic systems, disease is associated with a loss of complexity in system's output. We test the hypothesis that, in critically ill patients, there is an inverse relation between the complexity of the temperature curve and the clinical status. We also consider whether complexity analysis of the temperature curve may have prognostic value. DESIGN: Prospective, observational study. SETTING: Intensive care unit of a general hospital in Madrid, Spain. PATIENTS: Twenty-four successive patients admitted in the intensive care unit with multiple organ failure. INTERVENTIONS: Skin temperature was measured every 10 mins from inclusion in the study until discharge or death (median length of stay 18.8 days, interquartile range 86). MEASUREMENTS: From the temperature time series, hourly approximate entropy measurements were obtained. Clinical status was evaluated using the Sequential Organ Failure Assessment (SOFA) score. MAIN RESULTS: A significant inverse relationship between approximate entropy and the attributed SOFA score was observed in 89% of the patients considered. Both mean and minimum approximate entropy were significantly lower in patients who died than in patients who survived (mean approximate entropy, 0.47 vs. 0.61; minimum approximate entropy, 0.24 vs. 0.40; in both cases p < .001). To evaluate the prognostic value of both mean and minimum approximate entropy, we fitted logistic regression models against survival. An increase in 0.1 units in minimum or mean approximate entropy increased 15.4- and 18.5-fold the odds of surviving, respectively. CONCLUSIONS: The clinical status of patients suffering multiple organ failure is inversely correlated to the complexity of the temperature curve expressed as approximate entropy. Reduced complexity has dismal prognostic implications. Its assessment is noninvasive and inexpensive and allows for real-time continuous monitoring of clinical status.

Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial.

STUDY OBJECTIVE: Noninvasive mechanical ventilation (NIMV) is beneficial for patients with acute respiratory failure (ARF) when added to medical treatment. However, its role as an alternative to conventional mechanical ventilation (CMV) remains controversial. Our aim was to compare the efficacy and resource consumption of NIMV against CMV in patients with ARF. DESIGN: A randomized, multicenter, controlled trial. SETTING: Seven multipurpose ICUs. PATIENTS: Sixty-four patients with ARF from various causes who fulfilled criteria for mechanical ventilation. INTERVENTION: The noninvasive group received ventilation through a face mask in pressure-support mode plus positive end-expiratory pressure; the conventional group received ventilation through a tracheal tube. MEASUREMENTS AND RESULTS: Avoidance of intubation, mortality, and consumption of resources were the outcome variables. Thirty-one patients were assigned to the noninvasive group, and 33 were assigned to the conventional group. In the noninvasive group, 58% patients were intubated, vs 100% in the conventional group (relative risk reduction, 43%; p < 0.001). Stratification by type of ARF gave similar results. In the ICU, death occurred in 23% and 39% (p = 0.09) and complications occurred in 52% and 70% (p = 0.07) in the noninvasive and conventional groups, respectively. There were no differences in length of stay. The Therapeutic Intervention Score System-28, but not the direct nursing activity time, was lower in the noninvasive group during the first 3 days. CONCLUSIONS: NIMV reduces the need for intubation and therapeutic intervention in patients with ARF from different causes. There is a nonsignificant trend of reduction in ICUs and hospital mortality together with fewer complications during ICU stay.

Oxygen consumption measurement: agreement between the closed-circuit PhysioFlex anesthesia machine and the Deltatrac II indirect calorimeter.

UNLABELLED: We designed this study to ascertain whether, for the purpose of clinical interpretation, the direct measurement of O(2) consumption with the PhysioFlex closed-circuit anesthesia machine and with the Deltatrac II indirect calorimeter are interchangeable. Oxygen consumption was measured using the two instruments successively in critically-ill, mechanically-ventilated patients. Measurements were recorded as the mean of 10 consecutive, minute-by-minute, stable readings. The degree of agreement between the measurements obtained with the two systems was estimated using Bland-Altman analysis and the intraclass correlation coefficient. Forty-four pairs of measurements made in 21 patients were analyzed, yielding a mean bias of 6.32 mL/min and limits of agreement of 40.28 and -27.63 mL/min. The intraclass correlation coefficient was 0.95, and the 95% confidence interval ranged from 0.91 to 0.97. The measurement of O(2) consumption obtained with the PhysioFlex anesthesia machine is interchangeable with that obtained by indirect calorimetry. IMPLICATIONS: The PhysioFlex anesthesia machine (Dräger Inc., Lübeck, Germany) is a closed circuit anesthesia delivery device. The oxygen delivered by this device to maintain a steady-state inspired oxygen concentration is therefore a measure of the patient's oxygen consumption. This study was designed to evaluate the accuracy of the PhysioFlex for measuring oxygen consumption by comparing it with an established technology (Deltatrac II Calorimeter) for making this measurement.

Anestesia peridural para cesareas con fentanil asociado a bupivacaina en comparación con el uso de lidocaína, Centro quirúrgico del Hospital Nacional del Sur - IPSS, Arequipa

El presente ensayo clínico experimental se realizó en el Hospital Nacional del Sur. IPSS - Arequipa. Centro Quirúrgico. Servicio de Anestesiología en el periodo comprendido entre Enero a Diciembre de 1994. Se considera 75 pacientes, a 42 de ellas se les administró bipicaína asociada a fentalino y 33 pacientes con lidocaína. Para los pacientes en estudio y ambos grupos se consideró edad, nivel de punción tiempo quirúrgico, periodo de latencia, duración de la analgesia, presión arterial antes y durante el acto operatorio, en las mismas condiciones se registró la frecuencia cardiaca fetal y materna. Score Apgar del recién nacido. Analgesia post-operatoria, calidad anestésica, score del dolor, efectos colaterales maternos y fetales. El promedio etáreo apra el grupo tratado con bupivacaína asociada a fentanil fue de 32.7ñ5.46 años y para el tratado con lidocaína, 29.24ñ6.37 años. El tiempo quirúrgico lo mismo lo mismo que el tiempo de latencia y duración de la misma fue mayor para el grupo tratado con bupivacaína más fentanil. La presión arterial antes y durante el acto quirúrgico los mismos que la frecuencia cardiaca fetal y materna no mostraron diferencia significativa. El score Apgar fue similar en ambos grupos. La analgesia post operatoria, la calidad anestésica y la escala del dolor fueron mas adecuados para el primer grupo. La hipotensión arterial fue levemente superior para el segundo grupo pero en general hubo más efectos colaterales para el primero, del mismo modo los efectos colaterales fetales fueron similares en ambos grupos.