Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial.

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Outcomes of a multidisciplinary mechanical circulatory support network in cardiogenic shock in a centre without heart transplant program: A successful interprofessional coordination model.

BACKGROUND AND OBJECTIVE: Cardiogenic shock (CS) mortality remains very high and mechanical circulatory support (MCS) may provide an effective alternative of treatment in selected patients. The aim of this study is to analyse the results of a multidisciplinary team care program (including anaesthesiologists, cardiologists, cardiothoracic surgeons, and intensivists) in CS patients who required MCS, in a tertiary centre without a heart transplant (HT) program. METHODS: Prospective observational study that sought to analyse the characteristics and survival to discharge predictors in a consecutive CS patients cohort treated with MCS. RESULTS: A total of 48 patients were included. Mean age was 61 ± 14 years. Before MCS, 45.8% of the patients presented with cardiac arrest. A 54.2% 30-day survival and 45.8% overall survival to discharge, was found. Age and vasoactive-inotropic score were independent predictors of mortality. CONCLUSIONS: A multidisciplinary team-care based MCS program in CS patients is feasible and may achieve favourable results in a centre without HT program.

Resultados de un programa multidisciplinar de soporte circulatorio mecánico en shock cardiogénico en un centro sin programa de trasplante cardiaco: un modelo exitoso de coordinación entre profesionales / Outcomes of a multidisciplinary mechanical circulatory support network in cardiogenic shock in a centre without heart transplant program: A successful interprofessional coordination model

Antecedentes y objetivo: El shock cardiogénico (SC) conlleva una elevada mortalidad, y algunos pacientes pueden beneficiarse del uso de soporte circulatorio mecánico (SCM). El objetivo de este estudio es analizar los resultados de un programa multidisciplinar (constituido por anestesiología y reanimación, cardiología, cirugía cardiaca y medicina intensiva) de atención a pacientes en SC que precisaron SCM en un hospital terciario sin programa de trasplante cardiaco. (TC). Materiales y métodosEstudio prospectivo observacional que analiza las características y predictores de supervivencia hospitalaria de los pacientes con SC que precisaron SCM. Resultados: Se incluyeron 48 pacientes. Edad media 61±14años. El 45,8% presentaron parada cardiaca previa al implante. La supervivencia a 30días fue del 54,2% y la supervivencia al alta hospitalaria, del 45,8%. La edad y la escala de vasoactivos inotrópicos fueron predictores independientes de mortalidad. Conclusiones: La instauración de un programa multidisciplinar de SCM en un centro sin programa de TC es factible y aplicable a pacientes con SC, con resultados favorables en cuanto a supervivencia hospitalaria.(AU)

Background and objective: Cardiogenic shock (CS) mortality remains very high and mechanical circulatory support (MCS) may provide an effective alternative of treatment in selected patients. The aim of this study is to analyse the results of a multidisciplinary team care program (including anaesthesiologists, cardiologists, cardiothoracic surgeons, and intensivists) in CS patients who required MCS, in a tertiary centre without a heart transplant (HT) program. Methods: Prospective observational study that sought to analyse the characteristics and survival to discharge predictors in a consecutive CS patients cohort treated with MCS. Results: A total of 48 patients were included. Mean age was 61 ± 14 years. Before MCS, 45.8% of the patients presented with cardiac arrest. A 54.2% 30-day survival and 45.8% overall survival to discharge, was found. Age and vasoactive-inotropic score were independent predictors of mortality. Conclusions: A multidisciplinary team-care based MCS program in CS patients is feasible and may achieve favourable results in a centre without HT program.(AU)

[Sepsis Code: dodging mortality in a tertiary hospital]. / Código Sepsis: esquivando la mortalidad en un hospital terciario.

OBJECTIVE: In the hospital of La Princesa, the "Sepsis Code" (CSP) began in 2015, as a multidisciplinary group that provides health personnel with clinical, analytical and organizational tools, with the aim of the detection and early treatment of patients with sepsis. The objective of this study is to evaluate the impact of CSP implantation on mortality and to determine the variables associated with an increase in it. METHODS: A retrospective analytical study of patients with CSP alert activation from 2015 to 2018 was conducted. Clinical-epidemiological variables, analytical parameters, and severity factors such as admission to critical care units (UCC) and the need for amines were collected. Statistical significance was established at p < 0.05. RESULTS: We included 1,121 patients. The length of stay was 16 days and 32% required admission to UCC. Mortality showed a statistically significant linear downward trend from 24% in 2015 to 15% in 2018. The predictive mortality variables with statistically significant association were lactate > 2 mmol/L, creatinine > 1.6 mg/dL and the need for amines.>5.0%, mortality at the time of chart review 62.0%, and 6-months-post-discharge readmission 47.7%. CONCLUSIONS: The implementation of Sepsis Code decreases the mortality of patients with sepsis and septic shock. The presence of a lactate > 2 mmol/L, creatinine > 1.6 mg/dL and/or the need to administer amines in the first 24 hours, are associated with an increase in mortality in the patient with sepsis.

[Multiple cerebral haemorrhages secondary to disseminated intravascular coagulation in a patient with COVID-19]. / Hemorragias cerebrales múltiples secundarias a coagulación intravascular diseminada en un paciente con COVID-19.

TITLE: Hemorragias cerebrales múltiples secundarias a coagulación intravascular diseminada en un paciente con COVID-19.

Características, evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo, de cohorte y multicéntrico / Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: a prospective, cohort, multicentre study

ANTECEDENTES: No se ha reportado plenamente la evolución clínica de los pacientes críticos de COVID-19 durante su ingreso en la unidad de cuidados intensivos (UCI), incluyendo las complicaciones médicas e infecciosas y terapias de soporte, así como su asociación con la mortalidad en ICU. OBJETIVO: El objetivo de este estudio es describir las características clínicas y la evolución de los pacientes ingresados en UCI por COVID-19, y determinar los factores de riesgo de la mortalidad en UCI de dichos pacientes. MÉTODOS: Estudio prospectivo, multi-céntrico y de cohorte, que incluyó a los pacientes críticos de COVID-19 ingresados en 30 UCIs de España y Andorra. Se incluyó a los pacientes consecutivos de 12 de Marzo a 26 de Mayo de 2020 si habían fallecido o habían recibido el alta de la UCI durante el periodo de estudio. Se reportaron los datos demográficos, síntomas, signos vitales, marcadores de laboratorio, terapias de soporte, terapias farmacológicas, y complicaciones médicas e infecciosas, realizándose una comparación entre los pacientes fallecidos y los pacientes dados de alta. RESULTADOS: Se incluyó a un total de 663 pacientes. La mortalidad general en UCI fue del 31% (203 pacientes). Al ingreso en UCI los no supervivientes eran más hipoxémicos [SpO2 sin mascarilla de no reinhalación, de 90 (RIC 83-93) vs 91 (RIC 87-94); p < 0,001] y con mayor puntuación en la escala SOFA - Evaluación de daño orgánico secuencial - [SOFA, 7 (RIC 5-9) vs 4 (RIC 3-7); p < 0,001]. Las complicaciones fueron más frecuentes en los no supervivientes: síndrome de distrés respiratorio agudo (SDRA) (95% vs 89%; p = 0,009), insuficiencia renal aguda (IRA) (58% vs 24%; p < 10−16), shock (42% vs 14%; p < 10−13), y arritmias (24% vs 11%; p < 10−4). Las súper-infecciones respiratorias, infecciones del torrente sanguíneo y los shock sépticos fueron más frecuentes en los no supervivientes (33% vs 25%; p = 0,03, 33% vs 23%; p = 0,01 y 15% vs 3%, p = 10−7), respectivamente. El modelo de regresión multivariable reflejó que la edad estaba asociada a la mortalidad, y que cada año incrementaba el riesgo de muerte en un 1% (95%IC: 1-10, p = 0,014). Cada incremento de 5 puntos en la escala APACHE II predijo de manera independiente la mortalidad [OR: 1,508 (1,081, 2,104), p = 0,015]. Los pacientes con IRA [OR: 2,468 (1,628, 3,741), p < 10−4)], paro cardiaco [OR: 11,099 (3,389, 36,353), p = 0,0001], y shock séptico [OR: 3,224 (1,486, 6,994), p = 0,002] tuvieron un riesgo de muerte incrementado. CONCLUSIONES: Los pacientes mayores de COVID-19 con puntuaciones APACHE II más altas al ingreso, que desarrollaron IRA en grados II o III y/o shock séptico durante la estancia en UCI tuvieron un riesgo de muerte incrementado. La mortalidad en UCI fue del 31%

BACKGROUND: The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported. OBJECTIVE: This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients. METHODS: Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients. RESULTS: A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO2 with non-rebreather mask, 90 (IQR 83-93) vs 91 (IQR 87-94); p < 0.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5-9) vs 4 (IQR 3-7); p < 0.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs 89%; p = 0.009), acute kidney injury (AKI) (58% vs 24%; p < 10−16), shock (42% vs 14%; p < 10−13), and arrhythmias (24% vs 11%; p < 10−4). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs 25%; p = 0.03, 33% vs 23%; p = 0.01 and 15% vs 3%, p = 10−7), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1-10, p = 0.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), p = 0.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), p < 10−4)], cardiac arrest [OR: 11.099 (3.389, 36.353), p = 0.0001], and septic shock [OR: 3.224 (1.486, 6.994), p = 0.002] had an increased risk-of-death. CONCLUSIONS: Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades II or III and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study. / Características, evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo, de cohorte y multicéntrico.

BACKGROUND: The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported. OBJECTIVE: This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients. METHODS: Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients. RESULTS: A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO2 with non-rebreather mask, 90 (IQR 83 to 93) vs. 91 (IQR 87 to 94); P<.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5 to 9) vs. 4 (IQR 3 to 7); P<.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs. 89%; P=.009), acute kidney injury (AKI) (58% vs. 24%; P<10-16), shock (42% vs. 14%; P<10-13), and arrhythmias (24% vs. 11%; P<10-4). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs. 25%; P=.03, 33% vs. 23%; P=.01 and 15% vs. 3%, P=10-7), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1 to 10, P=.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), P=.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), P<10-4)], cardiac arrest [OR: 11.099 (3.389, 36.353), P=.0001], and septic shock [OR: 3.224 (1.486, 6.994), P=.002] had an increased risk-of-death. CONCLUSIONS: Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades ii or iii and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

Initial clinical outcomes and prognostic variables in the implementation of a Code Sepsis in a high complexity University Hospital.

OBJECTIVE: To assess the impact of the first months of application of a Code Sepsis in a high complexity hospital, analyzing patient´s epidemiological and clinical characteristics and prognostic factors. METHODS: A long-term observational study was carried out throughout a consecutive period of seven months (February 2015 - September 2015). The relationship with mortality of risk factors, and analytic values was analyzed using uni- and multivariate analyses. RESULTS: A total of 237 patients were included. The in-hospital mortality was 24% at 30 days and 27% at 60 days. The mortality of patients admitted to Critical Care Units was 30%. Significant differences were found between the patients who died and those who survived in mean levels of creatinine (2.30 vs 1.46 mg/dL, p <0.05), lactic acid (6.10 vs 2.62 mmol/L, p <0.05) and procalcitonin (23.27 vs 12.73 mg/dL, p<0.05). A statistically significant linear trend was found between SOFA scale rating and mortality (p<0.05). In the multivariate analysis additional independent risk factors associated with death were identified: age > 65 years (OR 5.33, p <0.05), lactic acid > 3 mmol/L (OR 5,85, p <0,05), creatinine > 1,2 mgr /dL (OR 4,54, p <0,05) and shock (OR 6,57, P <0,05). CONCLUSIONS: The epidemiological, clinical and mortality characteristics of the patients in our series are similar to the best published in the literature. The study has identified several markers that could be useful at a local level to estimate risk of death in septic patients. Studies like this one are necessary to make improvements in the Code Sepsis programs.

Búsqueda de biomarcadores para la identificación de pacientes quirúrgicos de alto riesgo cardiovascular y mortalidad perioperatoria elevada / Search for biomarkers to identify surgical patients at high cardiovascular and perioperative mortality risk

No disponible

Evolución de la saturación regional cerebral de oxígeno en el perioperatorio de cirugía torácica y su relación con la saturación venosa central / Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation

Objetivo. Estudiar la relación existente entre los valores de SvcO2 y de SrcO2 en la resección pulmonar con ventilación unipulmonar (VUP) y los cambios de dichas variables y de la presión arterial media (PAM) y la saturación arterial de oxígeno (SpO2) durante el periodo perioperatorio. Material y métodos. Estudio prospectivo observacional en 25 pacientes en quienes se realizó una resección pulmonar con VUP. Los valores de PAM, SpO2, SvcO2 y SrcO2 se registraron en 6 momentos diferentes: 1)basal; 2)en ventilación bipulmonar antes de la VUP (VBP1); 3)durante la VUP; 4)en ventilación bipulmonar después de la VUP (VBP2); 5)en los primeros 30min del postoperatorio, y 6)a las 6h de postoperatorio. Resultados. La SrcO2 mostró un aumento significativo desde su valor basal al iniciar la ventilación (65,72±9,05% vs 70,44±7,24%; p<0,01). No hubo cambios significativos en sus valores en los diferentes momentos intraoperatorios. En el postoperatorio, al igual que en el caso de la SvcO2, se observó una disminución significativa (p<0,001) de su valor en comparación con el valor previo. Conclusiones. La SrcO2 experimenta un aumento significativo tras la inducción de la anestesia e inicio de la ventilación mecánica respecto al valor basal y un descenso significativo al final de la cirugía, tras la extubación en el postoperatorio inmediato. Al tratarse de una monitorización tisular, no invasiva y continua, advierte al clínico de cambios en la relación DO2/VO2 en momentos de mayor riesgo como la VUP, la extubación y el periodo postoperatorio inmediato (AU)

Objective. To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period. Material and methods. Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery. Results. The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed. Conclusions. SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period (AU)

Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation. / Evolución de la saturación regional cerebral de oxígeno en el perioperatorio de cirugía torácica y su relación con la saturación venosa central.

OBJECTIVE: To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period. MATERIAL AND METHODS: Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery. RESULTS: The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed. CONCLUSIONS: SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period.

Descripción de los efectos hemodinámicos y respiratorios del tratamiento mediante hemoperfusión con polimixina B en pacientes con shock séptico de origen abdominal / Description of the hemodynamic and respiratory effects of hemoperfusion treatment with polymyxin B in patients with abdominal septic shock

En 11 de los 13 pacientes se realizaron 2 ciclos completos con el cartucho de polimixina y, en los otros 2, un solo ciclo. Tras este tratamiento, la presión arterial media (PAM) se incrementó (p = 0,003), disminuyó la necesidad de noradrenalina (p = 0,003) y la relación PO2/FiO2 aumentó (p = 0,02). La utilización precoz de hemoperfusión con polimixina en pacientes con shock séptico de origen intraabdominal puede mejorar de manera significativa las funciones hemodinámica y respiratoria. El objetivo de este estudio es describir la evolución hemodinámica, la dependencia a drogas inotrópicas y vasoactivas y analizar la relación PO2/FiO2 en 13 pacientes con shock séptico de origen abdominal después de emplear el tratamiento con hemoperfusión de polimixina. El tratamiento con hemoperfusión de polimixina es una terapia indicada para pacientes con sepsis grave o shock séptico de origen abdominal que no responden adecuadamente a la terapia convencional(AU)

The objective of this study is to describe the hemodynamic effects, inotropic and vasoactive drug dependence, and to analyze the PO2/FiO2 ratio in 13 patients with septic shock of abdominal origin after hemoperfusion treatment with polymyxin-B. Treatment with polymyxin hemoperfusion therapy is indicated for patients with severe sepsis/septic shock of abdominal origin who do not respond adequately to conventional therapy. Two complete cycles with polymyxin cartridge were performed on 11 of the 13 patients, and a single cycle on the other O2. After treatment, the mean airway pressure (MAP) was increased (P=.003), the need for norepinephrine decreased (P=.003), and the PO2/FiO2 ratio increased (P=.02). The use of polymyxin hemoperfusion in patients with septic shock of intra-abdominal origin can significantly improve hemodynamic and respiratory functions(AU)

[Description of the hemodynamic and respiratory effects of hemoperfusion treatment with polymyxin B in patients with abdominal septic shock]. / Descripción de los efectos hemodinámicos y respiratorios del tratamiento mediante hemoperfusión con polimixina B en pacientes con shock séptico de origen abdominal.

The objective of this study is to describe the hemodynamic effects, inotropic and vasoactive drug dependence, and to analyze the PO2/FiO2 ratio in 13 patients with septic shock of abdominal origin after hemoperfusion treatment with polymyxin-B. Treatment with polymyxin hemoperfusion therapy is indicated for patients with severe sepsis/septic shock of abdominal origin who do not respond adequately to conventional therapy. Two complete cycles with polymyxin cartridge were performed on 11 of the 13 patients, and a single cycle on the other O2. After treatment, the mean airway pressure (MAP) was increased (P=.003), the need for norepinephrine decreased (P=.003), and the PO2/FiO2 ratio increased (P=.02). The use of polymyxin hemoperfusion in patients with septic shock of intra-abdominal origin can significantly improve hemodynamic and respiratory functions.

[Double lumen tube insertion in awake patients through the AirTraq laryngoscope in 2 cases of expected difficult airway]. / Intubación con tubo de doble luz mediante laringoscopio Airtraq en dos pacientes despiertos con vía aérea díficil prevista.

The likelihood of difficult airway in thoracic surgery increases in the presence of associated cancer of the pharynx or larynx. The difficulty is greater when a double lumen tube must be inserted in these conditions, and various newly developed optical devices offer solutions for managing such cases. We report on 2 patients with expected difficult airway who were scheduled for lung resection. In both cases, intubation was accomplished through the AirTraq laryngoscope while the patient remained awake. Awake patient tolerance is facilitated by this laryngoscope, because the tube can be inserted without changing the position of the tongue or placing pressure on the vallecula.

Intubación con tubo de doble luz mediante laringoscopio Airtraq® en dos pacientes despiertos con vía aérea díficil prevista / Double lumen tube insertion in awake patients through the AirTraq laryngoscope in 2 cases of expected difficult airway

La posibilidad de hallar un paciente con vía aérea difícil (VAD) en cirugía torácica aumenta por la coexistencia de patología oncológica faringo-laríngea asociada. El uso de tubos de doble luz para el aislamiento pulmonar supone una dificultad añadida en estas situaciones. Diversos dispositivos ópticos diseñados en los últimos años, aportan nuevas soluciones disponibles para el manejo de estos casos. Presentamos dos pacientes con VAD conocida, programados para resección pulmonar, en los que se utilizó con éxito el laringoscopio Airtraq® para la inserción de tubo de doble luz con el paciente despierto. Este laringoscopio no requiere desplazamiento de la lengua, ni tracción de la vallécula, lo que facilita su tolerancia en pacientes despiertos(AU)

The likelihood of difficult airway in thoracic surgery increases in the presence of associated cancer of the pharynx or larynx. The difficulty is greater when a double lumen tube must be inserted in these conditions, and various newly developed optical devices offer solutions for managing such cases. We report on 2 patients with expected difficult airway who were scheduled for lung resection. In both cases, intubation was accomplished through the AirTraq laryngoscope while the patient remained awake. Awake patient tolerance is facilitated by this laryngoscope, because the tube can be inserted without changing the position of the tongue or placing pressure on the vallecula(AU)

Complications related to less-invasive haemodynamic monitoring.

BACKGROUND: The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™). METHODS: We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied. RESULTS: Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively. CONCLUSIONS: In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.