A 39-Year-Old Man With an Arteriovenous Malformation With New Dyspnea and Lower Limb Edema.

CASE PRESENTATION: A 39-year-old man with a history of arteriovenous malformation in the upper right limb that was complicated with vascular-type ulcers and repeated soft tissue infection and who had needed a supracondylar amputation of the limb when he was 27 years old presented a new soft tissue infection that manifested with fever, chills, increase in the diameter of the stump with local skin erythema, and painful necrotic ulcers. The patient reported mild dyspnea for 3 months (World Health Organization functional class II/IV) that had worsened during the last week (World Health Organization functional class III/IV) with chest tightness and bilateral lower limb edema.

Outcomes in Temporary ICUs Versus Conventional ICUs: An Observational Cohort of Mechanically Ventilated Patients With COVID-19-Induced Acute Respiratory Distress Syndrome.

Throughout the COVID-19 pandemic, thousands of temporary ICUs have been established worldwide. The outcomes and management of mechanically ventilated patients in these areas remain unknown. OBJECTIVES: To investigate mortality and management of mechanically ventilated patients in temporary ICUs. DESIGN SETTING AND PARTICIPANTS: Observational cohort study in a single-institution academic center. We included all adult patients with severe COVID-19 hospitalized in temporary and conventional ICUs for invasive mechanical ventilation due to acute respiratory distress syndrome from March 23, 2020, to April 5, 2021. MAIN OUTCOMES AND MEASURES: To determine if management in temporary ICUs increased 30-day in-hospital mortality compared with conventional ICUs. Ventilator-free days, ICU-free days (both at 28 d), hospital length of stay, and ICU readmission were also assessed. RESULTS: We included 776 patients (326 conventional and 450 temporary ICUs). Thirty-day in-hospital unadjusted mortality (28.8% conventional vs 36.0% temporary, log-rank test p = 0.023) was higher in temporary ICUs. After controlling for potential confounders, hospitalization in temporary ICUs was an independent risk factor associated with mortality (hazard ratio, 1.4; CI, 1.06-1.83; p = 0.016).There were no differences in ICU-free days at 28 days (6; IQR, 0-16 vs 2; IQR, 0-15; p = 0.5) or ventilator-free days at 28 days (8; IQR, 0-16 vs 5; IQR, 0-15; p = 0.6). We observed higher reintubation (18% vs 12%; p = 0.029) and readmission (5% vs 1.6%; p = 0.004) rates in conventional ICUs despite higher use of postextubation noninvasive mechanical ventilation (13% vs 8%; p = 0.025). Use of lung-protective ventilation (87% vs 85%; p = 0.5), prone positioning (76% vs 79%; p = 0.4), neuromuscular blockade (96% vs 98%; p = 0.4), and COVID-19 pharmacologic treatment was similar. CONCLUSIONS AND RELEVANCE: We observed a higher 30-day in-hospital mortality in temporary ICUs. Although both areas had high adherence to evidence-based management, hospitalization in temporary ICUs was an independent risk factor associated with mortality.

Clinicopathologic characteristics of severe COVID-19 patients in Mexico City: A post-mortem analysis using a minimally invasive autopsy approach.

OBJECTIVE: Describe the histological findings of minimally ultrasound-guided invasive autopsies in deceased patients with severe SARS-CoV-2 and compare the diagnostic yield with open autopsies. DESIGN: Observational post-mortem cohort study. Minimally invasive ultrasound-guided autopsies were performed in fourteen deceased patients with a confirmed diagnosis of SARS-CoV-2 pneumonia. Histological and clinical findings of lung, kidney, and liver tissue are described and contrasted with those previously reported in the literature. SETTING: Single-center COVID-19 reference center in Mexico City. RESULTS: Fourteen minimally invasive autopsies revealed a gross correlation with open autopsies reports: 1) Lung histology was characterized mainly by early diffuse alveolar damage (12/13). Despite low lung compliances and prolonged mechanical ventilation, the fibrotic phase was rarely observed (2/13). 2) Kidney histopathology demonstrated acute tubular injury (12/13), interstitial nephritis (11/13), and glomerulitis (11/13) as the predominant features 3) Liver histology was characterized by neutrophilic inflammation in all of the cases, as well as hepatic necrosis (8/14) despite minimal alterations in liver function testing. Hepatic steatosis was observed in most cases (12/14). SARS-CoV-2 positivity was widely observed throughout the immunohistochemical analysis. However, endothelitis and micro thrombosis, two of the hallmark features of the disease, were not observed. CONCLUSION: Our data represents the largest minimally invasive, ultrasound-guided autopsy report. We demonstrate a gross histological correlation with large open autopsy cohorts. However, this approach might overlook major histologic features of the disease, such as endothelitis and micro-thrombosis. Whether this represents sampling bias is unclear.

Surge in Ventilator-Associated Pneumonias and Bloodstream Infections in An Academic Referral Center Converted to Treat COVID-19 Patients

Background: Healthcare-associated infections (HAIs) are important adverse events that must be prevented. Objective: The objective of the study was to report and study possible changes in HAI rates as well as their causes after the COVID-19 hospital surge capacity response (HSCR) in an academic referral center. Methods: This was a before-after observational study. The Infection Prevention and Control (IPC) program (prospective surveillance, prevention bundles, antibiotic stewardship, continuing education, and feedback) was transiently disrupted after the start of HSCR (March 2020). HAI rates were compared before (January 2019-February 2020) and after (April-July 2020) HSCR, and plausible predisposing factors in affected patients were compared. Results: An increase in the HAI rate from 6.2 to 11.8 cases/1000 patient-days was noted between periods due to increases in ventilator-associated pneumonia and bloodstream infection (BSI) rates. More critically ill patients were admitted during HSCR, and use of invasive devices increased. Prone positioning and infusion of muscle relaxants became commonplace. The nurse-to-patient ratio in the intensive care unit decreased, and 4 h shifts were introduced to avoid fatigue. The BSI rate decreased after the IPC program with additional measures was reintroduced in May 2020. Conclusions: The strain on the workforce and modifications to the IPC program very possibly underlay the findings. IPC programs continue to be essential during the pandemic.

Educative Hybrid Intervention as a Strategy for Reintegration to the Clinical Courses of Undergraduate Students in COVID-19 Pandemic.

The SARS-CoV-2 pandemic generated the need to modify the current clinical educational model with the challenge of promoting safety and the continuity of clinical education through the use of virtual platforms. Since clinical training in hospital institutions cannot be substituted, a strategic training plan was developed to guarantee protection, safety, and academic continuity for students upon returning to clinical clerkships. The objective of this project was to develop and evaluate the impact of a massive hybrid training plan as an educative strategy to give the theoretical and practical knowledge required for the safe return of undergraduate students to their respective clinical activities in the context of this pandemic. An academic program was designed through a massive hybrid strategy to train 616 undergraduate students studying clinical cycles by presential, virtual, synchronous, and asynchronous activities. To know the program's impact, a study based on an initial evaluation and a final evaluation was carried out to evaluate the acquisition of the critical knowledge and skills of the program. A significant difference was found between the means of the initial and final evaluations (p <0.001), as well as a high impact of the intervention (d 1.6). Significant improvements in the areas of COVID-19 initial management (p <0.001) and personal protective equipment use (p <0.001) were seen in the post-test when compared to the initial evaluation. Both a quantitative and a qualitative analysis were carried out, finding positive results on the course design, quality of didactic resources, and instructors' performance. Massive hybrid training is an effective strategy to facilitate the reintegration of undergraduate students into their face-to-face clinical rotations.

Surge in Ventilator-Associated Pneumonias and Bloodstream Infections in An Academic Referral Center Converted to Treat COVID-19 Patients.

BACKGROUND: Healthcare-associated infections (HAIs) are important adverse events that must be prevented. OBJECTIVE: The objective of the study was to report and study possible changes in HAI rates as well as their causes after the COVID-19 hospital surge capacity response (HSCR) in an academic referral center. METHODS: This was a before-after observational study. The Infection Prevention and Control (IPC) program (prospective surveillance, prevention bundles, antibiotic stewardship, continuing education, and feedback) was transiently disrupted after the start of HSCR (March 2020). HAI rates were compared before (January 2019-February 2020) and after (April-July 2020) HSCR, and plausible predisposing factors in affected patients were compared. RESULTS: An increase in the HAI rate from 6.2 to 11.8 cases/1000 patient-days was noted between periods due to increases in ventilator-associated pneumonia and bloodstream infection (BSI) rates. More critically ill patients were admitted during HSCR, and use of invasive devices increased. Prone positioning and infusion of muscle relaxants became commonplace. The nurse-to-patient ratio in the intensive care unit decreased, and 4 h shifts were introduced to avoid fatigue. The BSI rate decreased after the IPC program with additional measures was reintroduced in May 2020. CONCLUSIONS: The strain on the workforce and modifications to the IPC program very possibly underlay the findings. IPC programs continue to be essential during the pandemic.

Detection of Pulmonary Shunts by Transcranial Doppler in Hospitalized Non-mechanically Ventilated Coronavirus Disease-19 Patients.

In severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated disease coronavirus disease 2019 (COVID-19), hypoxemia mechanisms differ from those observed in acute respiratory distress syndrome. Hypoxemia and respiratory failure in COVID- 19 are attributed to pulmonary angiopathy, increasing physiological pulmonary shunting1-3.

Outcomes of patients with COVID-19 in the intensive care unit in Mexico: A multicenter observational study.

BACKGROUND: As of June 15, 2020, a cumulative total of 7,823,289 confirmed cases of COVID-19 have been reported across 216 countries and territories worldwide. However, there is little information on the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to intensive care units (ICUs) in Latin America. The present study evaluated the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to ICUs in Mexico. METHODS: This was a multicenter observational study that included 164 critically ill patients with laboratory-confirmed COVID-19 who were admitted to 10 ICUs in Mexico, from April 1 to April 30, 2020. Demographic data, comorbid conditions, clinical presentation, treatment, and outcomes were collected and analyzed. The date of final follow-up was June 4, 2020. RESULTS: A total of 164 patients with severe COVID-19 were included in this study. The mean age of patients was 57.3 years (SD 13.7), 114 (69.5%) were men, and 6.0% were healthcare workers. Comorbid conditions were common in patients with critical COVID-19: 38.4% of patients had hypertension and 32.3% had diabetes. Compared to survivors, nonsurvivors were older and more likely to have diabetes, hypertension or other conditions. Patients presented to the hospital a median of 7 days (IQR 4.5-9) after symptom onset. The most common presenting symptoms were shortness of breath, fever, dry cough, and myalgias. One hundred percent of patients received invasive mechanical ventilation for a median time of 11 days (IQR 6-14). A total of 139 of 164 patients (89.4%) received vasopressors, and 24 patients (14.6%) received renal replacement therapy during hospitalization. Eighty-five (51.8%) patients died at or before 30 days, with a median survival of 25 days. Age (OR, 1.05; 95% CI, 1.02-1.08; p<0.001) and C-reactive protein levels upon ICU admission (1.008; 95% CI, 1.003-1.012; p<0.001) were associated with a higher risk of in-hospital death. ICU length of stay was associated with reduced in-hospital mortality risk (OR, 0.89; 95% CI, 0.84-0.94; p<0.001). CONCLUSIONS: This observational study of critically ill patients with laboratory-confirmed COVID-19 who were admitted to the ICU in Mexico demonstrated that age and C-reactive protein level upon ICU admission were associated with in-hospital mortality, and the overall hospital mortality rate was high. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04336345.

Prolonged Intermittent Renal Replacement Therapy for Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome.

INTRODUCTION: Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI. METHODS: We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose. RESULTS: We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36-73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7-14) days. The median of PIRRT procedures for each patient was 5 (IQR 4-9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4-28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3-12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented. CONCLUSIONS: PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.

Impacto de las asincronías en el pronóstico del paciente bajo ventilación mecánica invasiva / Prognosis impact of the asynchronies in the mechanical ventilated patient / Impacto das assincronias no prognóstico do paciente com ventilação mecânica invasiva

Resumen: La ventilación mecánica es común en pacientes críticos. La asincronía paciente-ventilador existe cuando las fases de la respiración administradas por el ventilador no coinciden con las del paciente. Las asincronías son frecuentes e infradiagnosticadas, éstas se han asociado con desenlaces desfavorables como son: mayor duración de ventilación mecánica, estancia en la unidad de terapia intensiva, mortalidad, incomodidad del paciente, alteraciones del sueño y disfunción diafragmática. Esta revisión describe los desenlaces adversos reportados que se han asociado a la presencia de asincronías en pacientes adultos bajo ventilación mecánica invasiva. La evidencia actual sugiere que el mejor enfoque para manejar las asincronías es ajustar la configuración del ventilador y mejorar su detección. Si bien la mayoría de la evidencia proviene de estudios observacionales y ensayos clínicos aleatorizados realizados en poblaciones heterogéneas y con un número limitado de pacientes, los resultados sugieren desenlaces desfavorables clínicamente significativos en los pacientes que experimentan un índice de asincronía elevado. Por lo anterior, es necesario generar mayor evidencia en este tópico.

Abstract: Mechanical ventilation is common in critically ill patients. Patient-ventilator asynchrony exists when the breathing phases administered by the ventilator do not match those of the patient. They are frequent but underdiagnosed, and have been associated with worse outcomes because they negatively affect patient comfort, length of mechanical ventilation, length of stay in the intensive care unit and mortality. This review describes the negative outcomes associated with the presence of asynchronies in adult patients with invasive mechanical ventilation. Current evidence suggests that the best approach to handle asynchronies is to adjust the fan settings and improve the quality of detection. While most of this evidence comes from observational studies and randomized clinical trials which were done with heterogeneous populations and a limited number of patients, the results suggest less favorable clinically significant outcomes in patients with asynchronies. So it is necessary to generate more evidence in this topic.

Resumo: A ventilação mecânica é comum em pacientes críticos. A assincronia paciente-ventilador existe quando as fases da respiração fornecida pelo ventilador não coincidem com as do paciente. As assincronas são frequentes e subdiagnosticadas, tendo sido associadas a desfechos desfavoráveis como: maior tempo de ventilação mecânica, permanência em unidade de terapia intensiva, mortalidade, desconforto do paciente, distúrbios do sono e disfunção diafragmática. Esta revisão descreve os resultados adversos relatados que foram associados à presença de assincronia em pacientes adultos sob ventilação mecânica invasiva. A evidência atual sugere que a melhor abordagem para gerenciar assincronias é ajustar as configurações do ventilador e melhorar a detecção do ventilador. Embora a maioria das evidências provenha de estudos observacionais e ensaios clínicos randomizados conduzidos em populações heterogêneas e com um número limitado de pacientes, os resultados sugerem resultados clinicamente desfavoráveis significativos em pacientes que apresentam uma alta taxa de assincronia. Portanto, é necessário gerar mais evidências sobre este tema.

CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTS DIAGNOSED WITH COVID-19 IN A TERTIARY CARE CENTER IN MEXICO CITY: A PROSPECTIVE COHORT STUDY.

BACKGROUND: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. OBJECTIVE: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). METHODS: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. RESULTS: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. CONCLUSIONS: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Clinical and epidemiological characteristics of patients diagnosed with covid-19 in a tertiary care center in Mexico City: a prospective cohort study

ABSTRACT Background: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Near-zero ventilator-associated pneumonia rates after implementation of a multimodal preventive strategy in a Mexican hospital.

A multimodal preventive strategy consisting of a ventilator-associated pneumonia (VAP) preventive bundle plus 3 additional sequential interventions (noninvasive ventilation, reeducation of health care workers, and early weaning) was associated with a marked reduction in VAP rates in a Latin American hospital, including 6 consecutive months without VAP cases. A positive association between the percentage of intubated patients and VAP rates was observed.

Choque cardiogénico: de la definición al abordaje / Cardiogenic shock: from definition to the approach / Choque cardiogênico: da definição à abordagem

Resumen: El choque cardiogénico es la mayor catástrofe del infarto agudo al miocardio y de las cardiopatías en general. Se define como un estado en el cual el gasto cardiaco es ineficiente para perfundir y oxigenar los tejidos, por lo que se manifiesta con signos de hipoperfusión tisular y congestión capilar. Aunque las últimas guías no exijan el diagnóstico por medio de medidas hemodinámicas, el basarse sólo en lo clínico puede generar errores hasta en 30%. Las causas se dividen en isquémicas y no isquémicas, siendo la primera la más común. Pese a la aparición de nuevos dispositivos mecánicos, aunados al soporte médico, sólo se ha demostrado la mejora de los desenlaces con las terapias endovasculares.

Abstract: Cardiogenic shock (CSh) is the major catastrophe of acute myocardial infarction (AMI) and heart disease in general. It is defined as a state in which cardiac output (CO) is inefficient to perfuse and oxygenate tissues, which is why it manifests with signs of tissue hypoperfusion and capillary congestion. Although the latest guidelines do not require diagnosis with hemodynamic measures, relying only on the clinical can generate errors up to 30%. The causes are divided into ischemic (AMI) and non-ischemic, with the former being the most common. Despite the appearance of new mechanical devices, coupled with medical support, it has only shown the improvement of outcomes with endovascular therapies.

Resumo: O choque cardiológico (ChC) é a principal catástrofe do infarto agudo do miocárdio (IAM) e das cardiopatias em geral. Definida como um estado no qual o débito cardíaco (DC) é ineficiente para perfundir e oxigenar os tejidos, razão pela qual se manifiesta com sinais de hipoperfusão tecidual e congestão capilar. Embora as diretrizes mais recentes não exijam diagnóstico por meio de medidas hemodinâmicas, depender apenas da clínica pode gerar erros de até 30%. As causas são divididas em isquêmicas (IAM) e não isquêmicas, sendo a primeira a mais comum. Apesar do surgimento de novos dispositivos mecânicos aliados ao suporte médico, só demonstrou-se a melhora dos resultados com terapias endovasculares.

A 50-Year-Old Woman With Uterine Myomatosis, Rapidly Progressive Dyspnea, and Lower Extremity Edema.

CASE PRESENTATION: A 50-year-old woman with morbid obesity (BMI, 49 kg/m2) was admitted to the ED due to shortness of breath triggered by mild to moderate efforts over the previous 3 weeks that rapidly progressed to dyspnea at rest and became associated with oppressive chest pain and edema of the lower extremities. Four months prior to admission, she had been diagnosed with a uterine mass (18 × 21 cm2) suggestive of a leiomyoma, manifesting with abnormal vaginal bleeding and microcytic hypochromic anemia (Fig 1).

A 44-Year-Old Woman With Sudden Breathlessness, Tightness in Chest, and Hypotension After Extubation in the Early Postoperative Period After Liver Transplantation.

CASE PRESENTATION: A 44-year-old woman with Child-Pugh class C cirrhosis due to primary biliary cirrhosis and mild portopulmonary syndrome received a liver transplant. Her basal catheterization showed a mean pulmonary arterial pressure (mPAP) of 28 mm Hg, pulmonary artery occlusion pressure (PAOP) of 8 mm Hg, pulmonary vascular resistance (PVR) of 307 dynes.s.cm-5, and a cardiac output of 5.2 L/min. The echocardiogram did not reveal right ventricular dilatation (mid-diameter of 34 mm). In surgery, hemodynamic assessment showed an mPAP of 25 mm Hg, PAOP of 6 mm Hg, PVR of 262 dynes.s.cm-5 and cardiac output of 5.8 L/min. During the anhepatic period, the patient required norepinephrine (0.4 µg/kg/min) but had no complications during reperfusion; throughout surgery, her mPAP was never > 30 mm Hg. At the end of surgery, the brain natriuretic peptide level was 66 pg/mL (< 100 pg/mL). One day following transplantation, the patient remained hemodynamically stable and was therefore weaned from mechanical ventilation. However, 6 h following extubation, she reported breathlessness and tightness in chest, and developed sudden arterial hypotension, oxygen desaturation, and oliguria.

Pronóstico de pacientes con lupus eritematoso generalizado en una unidad de cuidados intensivos.

INTRODUCCIÓN: La identificación de factores de riesgo para mortalidad ha permitido mejorar el tratamiento de los pacientes críticos con lupus eritematosos generalizado. OBJETIVO: Describir las características clínicas y los pronósticos de pacientes graves con lupus eritematosos generalizado ingresados en una unidad de cuidados intensivos. MÉTODO: Estudio de cohorte, observacional y descriptivo. Se incluyeron 207 pacientes con lupus eritematosos generalizado enero de 2011 y enero de 2016. RESULTADOS: Durante el periodo del estudio fueron ingresados 3215 pacientes graves a una unidad de cuidados intensivos, 207 (6.4 %) con lupus eritematosos generalizado después de ser evaluados por un intensivista. La mortalidad fue de 18.4 %. El análisis multivariado identificó la presencia fallas orgánicas (cardiovascular, hepática y neurológica) y niveles séricos de lactato > 2 mmol/L al ingreso o durante las primeras 24 horas de estancia en la unidad de cuidados intensivos como los principales factores asociados con incremento de la mortalidad. CONCLUSIONES: Un dato relevante fue que la falla neurológica y la falla hepática estuvieron asociadas con mayor riesgo de muerte a 28 días, sin que identificáramos reportes similares a estos hallazgos. INTRODUCTION: Identification of risk factors for mortality has enabled improving the treatment of critically ill patients with systemic lupus erythematosus. OBJECTIVE: To describe clinical characteristics and prognoses of critically ill patients with systemic lupus erythematosus admitted to an intensive care unit. METHOD: Prospective, observational cohort study. A total of 207 patients with systemic lupus erythematosus admitted between January 2011 and January 2016 were included. RESULTS: During the study period, 3,215 critically ill patients were admitted to the intensive care unit, out of which 207 (6.4%) were identified as having systemic lupus erythematosus after being evaluated by an intensivist. The multivariate analysis identified the presence of organ failure (cardiovascular, liver, neurological) and serum lactate levels > 2 mmoL/L at admission or within the first 24 hours of intensive care unit stay as the main factors associated with increased mortality. CONCLUSIONS: A relevant observation was that neurological failure and liver failure were associated with higher mortality risk at 28 days, without reports similar to these findings being identified.

Pulmonary Vasoreactivity and Phenotypes in Pulmonary Arterial Hypertension Associated to Connective Tissue Diseases.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a fatal complication in patients with connective tissue disease (CTD). OBJECTIVE: The objective of the study was to study the prognostic value of the acute pulmonary vasoreactivity test with inhaled iloprost and its association with clinical deterioration in a tertiary care academic medical center. METHODS: We conducted a prospective study of patients with CTD and the diagnosis of PAH established by right heart catheterization. Patients were classified into classic responders, partial responders, and non-responders. The association of the pulmonary response and clinical deterioration was analyzed. RESULTS: We enrolled 25 patients (mean age of 47 ± 13.4 years); 88% were female. The most frequent rheumatologic diagnosis was systemic lupus erythematosus, in 16 (64%) patients. Seventy-two percent of patients were classified as non-responders, and 28% were partial responders. Patients with a partial response had lower right atrial pressure values (5.1 ± 3.1 vs. 8.5 ± 3.2, p = 0.01) and greater systolic pulmonary arterial pressure (87.6 ± 8.1 vs. 72.4 ± 16.2, p = 0.02), compared with non-responders. Non-responders had a tendency for a shorter time to clinical deterioration than partial responders (17.8 vs. 41.1 months, p = 0.052). CONCLUSIONS: Patients with a partial response to the acute pulmonary vasodilator test with inhaled iloprost had a longer clinical deterioration-free period than non-responders.