Structural differences in the diaphragm of patients following controlled vs assisted and spontaneous mechanical ventilation.

PURPOSE: Ventilator-induced diaphragm dysfunction or damage (VIDD) is highly prevalent in patients under mechanical ventilation (MV), but its analysis is limited by the difficulty of obtaining histological samples. In this study we compared diaphragm histological characteristics in Maastricht III (MSIII) and brain-dead (BD) organ donors and in control subjects undergoing thoracic surgery (CTL) after a period of either controlled or spontaneous MV (CMV or SMV). METHODS: In this prospective study, biopsies were obtained from diaphragm and quadriceps. Demographic variables, comorbidities, severity on admission, treatment, and ventilatory variables were evaluated. Immunohistochemical analysis (fiber size and type percentages) and quantification of abnormal fibers (a surrogate of muscle damage) were performed. RESULTS: Muscle samples were obtained from 35 patients. MSIII (n = 16) had more hours on MV (either CMV or SMV) than BD (n = 14) and also spent more hours and a greater percentage of time with diaphragm stimuli (time in assisted and spontaneous modalities). Cross-sectional area (CSA) was significantly reduced in the diaphragm and quadriceps in both groups in comparison with CTL (n = 5). Quadriceps CSA was significantly decreased in MSIII compared to BD but there were no differences in the diaphragm CSA between the two groups. Those MSIII who spent 100 h or more without diaphragm stimuli presented reduced diaphragm CSA without changes in their quadriceps CSA. The proportion of internal nuclei in MSIII diaphragms tended to be higher than in BD diaphragms, and their proportion of lipofuscin deposits tended to be lower, though there were no differences in the quadriceps fiber evaluation. CONCLUSIONS: This study provides the first evidence in humans regarding the effects of different modes of MV (controlled, assisted, and spontaneous) on diaphragm myofiber damage, and shows that diaphragm inactivity during mechanical ventilation is associated with the development of VIDD.

La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico / Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis

OBJETIVOS: Determinar la prevalencia de hipovitaminosis D al ingreso en el Servicio de Medicina Intensiva (SMI), así como su asociación con el pronóstico del paciente crítico. DISEÑO: Análisis observacional prospectivo llevado a cabo desde enero a noviembre de 2015. Los pacientes incluidos fueron seguidos hasta su fallecimiento o alta hospitalaria. Ámbito: SMI polivalente de un hospital universitario. PACIENTES: Todos los individuos adultos que ingresaron en el SMI durante el periodo de estudio y que no presentaban factores conocidos que pudieran alterar los valores sanguíneos de 25(OH)D. INTERVENCIONES: Determinación de los niveles séricos de 25(OH)D en las primeras 24 h de ingreso en el SMI. Principales variables de interés: Prevalencia de hipovitaminosis D al ingreso en UCI y mortalidad a los 28 días. RESULTADOS: Se incluyeron 135 individuos. El 74% de los pacientes presentó niveles bajos de 25(OH)D en el momento de su ingreso en el SMI. El grupo de pacientes que fallecieron presentaba niveles significativamente inferiores al grupo de pacientes que sobrevivieron (8,14 ng/mL [6,17-11,53] vs. 12 ng/mL [7,1-20,30], p = 0,04) y el valor en sangre de 25(OH)D al ingreso se mostró como factor de riesgo independiente en el análisis multivariado (OR 2,86; IC 95% 1,05-7,86, p = 0,04). La curva ROC fue de 0,61 (IC 95% 0,51-0,75) y el mejor punto de corte para predecir mortalidad fue de 10,9 ng/mL. Los pacientes con valores de 25(OH)D < 10,9 ng/mL también presentaron mayores tasas de fracaso renal agudo (13 vs. 29%, p = 0,02). CONCLUSIÓN: Existe una elevada prevalencia de hipovitaminosis D en el momento de ingreso en el SMI. La hipovitaminosis D severa (25[OH]D < 10,9 ng/mL) al ingreso en el SMI se asocia a mayor incidencia de fracaso renal agudo y mayor mortalidad

OBJECTIVES: To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. DESIGN: A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. SETTING: The department of Critical Care Medicine of a university hospital. PATIENTS: All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. INTERVENTIONS: Determination of serum 25(OH)D levels within the first 24 h following admission to the ICU. Main variables of interest: Prevalence and mortality at 28 days. RESULTS: The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14 ng/ml [6.17-11.53] vs. 12 ng/ml [7.1-20.30]; P = .04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P = .04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9 ng/ml. Patients with serum 25(OH)D < 10.9 ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P = .02). CONCLUSION: Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D < 10.9 ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis. / La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico.

OBJECTIVES: To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. DESIGN: A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. SETTING: The department of Critical Care Medicine of a university hospital. PATIENTS: All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. INTERVENTIONS: Determination of serum 25(OH)D levels within the first 24h following admission to the ICU. MAIN VARIABLES OF INTEREST: Prevalence and mortality at 28 days. RESULTS: The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02). CONCLUSION: Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality.

Papel de la oxigenoterapia de alto flujo en la insuficiencia respiratoria aguda / The role of high flow oxygen therapy in acute respiratory failure

La insuficiencia respiratoria aguda supone una de las causas más frecuentes de ingreso en los servicios de Medicina Intensiva y la oxigenoterapia sigue constituyendo una terapéutica de primera línea en el manejo de estos pacientes. En los últimos años, la oxigenoterapia de alto flujo ha sido descrita como una alternativa útil a la oxigenoterapia convencional en los pacientes con insuficiencia respiratoria aguda. La oxigenoterapia de alto flujo permite administrar un flujo de gas totalmente acondicionado hasta a 60 L/min mediante cánulas nasales, obteniendo una rápida mejoría de los síntomas debido a diferentes mecanismos como, por ejemplo, una reducción de la resistencia de la vía aérea superior, cambios en el volumen circulante y la generación de cierto grado de presión positiva. Además, todo ello se consigue junto con una mejor tolerancia y comodidad por parte del paciente. Sin embargo, la experiencia en adultos es todavía limitada y no existen guías clínicas que establezcan recomendaciones para su uso. En este artículo se pretende revisar la evidencia existente sobre el uso de oxigenoterapia de alto flujo en pacientes adultos con insuficiencia respiratoria aguda, así como sus posibles aplicaciones, ventajas y limitaciones (AU)

Acute respiratory failure represents one of the most common causes of intensive care unit admission and oxygen therapy remains the first-line therapy in the management of these patients. In recent years, high-flow oxygen via nasal cannula has been described as a useful alternative to conventional oxygen therapy in patients with acute respiratory failure. High-flow oxygen via nasal cannula rapidly alleviates symptoms of acute respiratory failure and improves oxygenation by several mechanisms, including dead space washout, reduction in oxygen dilution and inspiratory nasopharyngeal resistance, a moderate positive airway pressure effect that may generate alveolar recruitment and an overall greater tolerance and comfort with the interface and the heated and humidified inspired gases. However, the experience in adults is still limited and there are no clinical guidelines to establish recommendations for their use. This article aims to review the existing evidence on the use of high-flow oxygen via nasal cannula in adults with acute respiratory failure and its possible applications, advantages and limitations (AU)

The role of high flow oxygen therapy in acute respiratory failure.

Acute respiratory failure represents one of the most common causes of intensive care unit admission and oxygen therapy remains the first-line therapy in the management of these patients. In recent years, high-flow oxygen via nasal cannula has been described as a useful alternative to conventional oxygen therapy in patients with acute respiratory failure. High-flow oxygen via nasal cannula rapidly alleviates symptoms of acute respiratory failure and improves oxygenation by several mechanisms, including dead space washout, reduction in oxygen dilution and inspiratory nasopharyngeal resistance, a moderate positive airway pressure effect that may generate alveolar recruitment and an overall greater tolerance and comfort with the interface and the heated and humidified inspired gases. However, the experience in adults is still limited and there are no clinical guidelines to establish recommendations for their use. This article aims to review the existing evidence on the use of high-flow oxygen via nasal cannula in adults with acute respiratory failure and its possible applications, advantages and limitations.