The role of routine FIBERoptic bronchoscopy monitoring during percutaneous dilatational TRACHeostomy (FIBERTRACH): a study protocol for a randomized, controlled clinical trial.

BACKGROUND: Tracheostomy is one of the most frequent techniques in intensive care units (ICU). Fiberoptic bronchoscopy (FB) is a safety measure when performing a percutaneous dilatational tracheostomy (PDT), but the controversy surrounding the routine use of FB as part of the procedure remains open. National surveys in some European countries showed that the use of FB is non-standardized. Retrospective studies have not shown a significant difference in complications between procedures performed with or without a bronchoscope. International guidelines have not been able to establish recommendations regarding the use of FB in PDT due to lack of evidence. DESIGN: This is a multicenter (three centers at the time of  publishing this paper) randomized controlled clinical trial to examine the safety of percutaneous tracheostomy using FB. We will include all consecutive adult patients admitted to the ICU in whom percutaneous tracheostomy for prolonged mechanical ventilation is indicated and with no exclusion criteria for using FB. Eligible patients will be randomly assigned to receive blind PDT or PDT under endoscopic guidance. All procedures will be performed by experienced intensivists in PDT and FB. A Data Safety and Monitoring Board (DSMB) will monitor the trial. The primary outcome is the incidence of perioperative complications. DISCUSSION: FB is a safe technique when performing PDT although its use is not universally accepted in all ICUs as a routine practice. Should PDT be monitored routinely with endoscopic guidance? This study will assess the role of FB monitoring during PDT. TRIAL REGISTRATION: ClinicalTrials.gov NCT04265625. Registered on February 11, 2020.

Digestive decontamination in burn patients: A systematic review of randomized clinical trials and observational studies.

OBJECTIVE: The objective of this systematic review is to assess the effect of selective digestive decontamination (SDD) or non-absorbable enteral antibiotics (EA) on mortality, the incidence of infection and its adverse effects in burn patients. MATERIAL AND METHODS: Systematic review of randomized clinical trials (RCT) or observational studies enrolling burn patients, and comparing SDD or EA prophylaxis with placebo or no treatment. The search includes Pubmed/Medline, EMBASE, WOS, Cochrane Library (1970-2015). Bibliographic references were also reviewed, as well as communications presented at conferences (2012-2015), without language restrictions. Two reviewers inspected each reference identified by the search independently; the risk of bias was assessed with the Cochrane Collaboration method for RCT and the Newcastle Ottawa Scale for observational studies. RESULTS: Five RCT and 5 observational studies were identified enrolling a total of 1680 patients. The overall methodological quality of the studies was poor. The pooled effect of RCT using EA was OR: 0.62 (95% CI: 0.20-1.94). The only RCT using SDD reported OR 0.20 (95% CI: 0.09-0.81). The incidence of Enterobacteriaceae bloodstream was lower in cases treated with SDD or EA. The incidence of pneumonia was only reduced in the studies using SDD. None of the studies reported an increase in antibiotic resistance but in one RCT SDD was associated to an increase in methicillin-resistant Staphylococcus aureus infections, that was controlled with enteral vancomycin. CONCLUSIONS: SDD and EA have shown a beneficial effect in burn patients. Both practices are safe. Higher quality RCTs should be conducted to properly assess the efficacy and safety of SDD in this population.

Estado actual de la descontaminación digestiva selectiva / Current state of decontamination selective digestive

La descontaminación digestiva selectiva (DDS) es una estrategia preventiva cuyo objetivo es reducir la incidencia de infecciones en los pacientes críticos, principalmente la neumonía asociada a ventilación mecánica (NAVM). Fue descrita en 1984 por Stoutenbeek et al.1 . Desde entonces, se han realizado 66 ensayos clínicos aleatorizados (ECA) y 13 meta-análisis que consistentemente demuestran que la DDS reduce la incidencia de NAVM, bacteriemias, infección por Candida sp. y la mortalidad de los pacientes críticos. En esta breve puesta al día, se revisan los fundamentos de esta práctica y su impacto en el cuidado de los enfermos críticos. Se ha excluido el análisis de su efecto sobre grupos con patologías específicas tales como quemaduras, transplante hepático, pancreatitis, cirugía digestiva, etc

Genetic predisposition to acute kidney injury induced by severe sepsis.

PURPOSE: The aim of this study was to demonstrate that candidate gene polymorphisms are associated with an increased risk of acute kidney injury (AKI). MATERIALS AND METHODS: Patients admitted to the intensive care unit with the diagnosis of severe sepsis and an expected intensive care unit length of stay more than 48 hours were included. Genetic polymorphisms studied included angiotensin-converting enzyme insertion/deletion (polymerase chain reaction); tumor necrosis factor α -376, - 308, and -238; interleukin-8 -251; vascular endothelial growth factor (VEGF) +405 and +936; and pre-B-cell colony-enhancing factor -1001 (TaqMan SNP genotyping assay, Life Technologies, Grand Island, NY). Acute kidney injury was defined as the risk, injury, and failure categories, as per the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification. RESULTS: One hundred thirty-nine patients were included, 65 of whom developed AKI. In univariate analysis, the VEGF +936 CC and the pre-B-cell colony-enhancing factor -1001 GG genotypes were associated with AKI. In multivariate analysis, Simplified Acute Physiology Score II score (odds ratio [95% confidence interval], 1.06 [1.03-1.09]), chronic arterial hypertension (3.15 [1.39-7.15]), and the presence of the VEGF +936 CC genotype (3.41 [1.19-9.79]) were associated with AKI. CONCLUSION: This is the first study demonstrating an association between the VEGF +936 CC genotype and the risk to develop AKI in patients with severe sepsis.

Genetic predisposition to acute respiratory distress syndrome in patients with severe sepsis.

OBJECTIVE: The objective of this study was to analyze the association between candidate gene polymorphisms and susceptibility to acute respiratory distress syndrome (ARDS) in patients with severe sepsis. METHODS: Patients older than 18 years admitted to the intensive care unit (ICU) with the diagnosis of severe sepsis were prospectively included. A blood sample was drawn on the first day of ICU admission, and DNA was extracted. We genotyped the insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) gene (polymerase chain reaction) and the following single-nucleotide polymorphisms (TaqMan SNP genotyping assay): tumor necrosis factor α -376 G/A, -308 G/A, and -238 G/A; interleukin 8 -251 T/A; pre-B cell colony-enhancing factor -1001 G/T; and vascular endothelial growth factor +405 C/G and +936 C/T. Polymorphisms were selected based on reports on their association with ARDS. Variables associated in univariate analysis (P < 0.1) with the diagnosis of ARDS were included in a multiple logistic regression analysis. RESULTS: We studied 149 patients, of whom 35 presented ARDS. Variables included in the maximal multivariate model were male sex, chronic alcoholism, use of ACE inhibitors or angiotensin-receptor blockers, Simplified Acute Physiology Score II score, serum glucose concentration at ICU admission, and the presence of the allele D of the ACE gene. After adjustment for those variables, the presence of the allele D of the ACE gene (odds ratio, 4.75; 95% confidence interval, 1.02-22.20; P = 0.048) was significantly associated with the diagnosis of ARDS. CONCLUSION: The presence of the allele D of the ACE gene is associated with ARDS in patients with severe sepsis.

Chronology of histological lesions in acute respiratory distress syndrome with diffuse alveolar damage: a prospective cohort study of clinical autopsies.

BACKGROUND: Diffuse alveolar damage is the histological hallmark of acute respiratory distress syndrome (ARDS). However, the chronology of histological lesions is not well established. We aimed to determine the time to onset of exudative or proliferative changes and end-stage fibrosis in ARDS. METHODS: We analysed all patients who died between Jan 1, 1991, and Dec 31, 2010, in the intensive-care unit at the Hospital Universitario de Getafe, Madrid, Spain, and who had a clinical autopsy. Patients had to have clinical criteria for ARDS at time of death and histological features of diffuse alveolar damage at autopsy examination. Capillary congestion and intra-alveolar oedema characterised the exudative phase whereas proliferation of alveolar cell type 2 or fibroblasts, or fibrosis characterised the proliferative phase. FINDINGS: We analysed 159 patients. The prevalence of exudative changes decreased over time, being reported in 74 (90%) of 82 patients with ARDS of less than 1 week duration, 40 (74%) of 54 patients with disease of 1-3 week duration, and only four (17%) of 23 patients with disease of longer than 3 weeks' duration (p<0·0001). The incidence of proliferative changes increased over time, and was reported in 44 (54%) of 82 patients with ARDS of less than 1-week duration, 42 (78%) of 54 patients with disease duration of 1-3 weeks, and 23 (100%) of 23 patients with disease duration longer than 3 weeks (p<0·0001). Fibrosis was noted in three (4%) of 82 patients with disease of less than 1 week duration, 13 (24%) of 54 patients with disease of 1-3-weeks' duration, and 14 (61%) of 23 patients with disease longer than 3-week duration (p<0·0001). Fibrosis was more frequent in ARDS of pulmonary origin than in that of extrapulmonary origin. INTERPRETATION: Histological features of the lungs were related to duration of ARDS. Within the first week of evolution, exudative changes were predominant and fibrosis was rarely noted. Beyond the third week of evolution, proliferative changes were noted in all patients and fibrosis in two-thirds of them. Treatments with a potential effect on inflammation or fibrosis, or both, should probably focus on the first week after the onset of ARDS. FUNDING: None.