Síndrome de respuesta inflamatoria sistémica en cuidados intensivos pediátricos

Introducción: La sepsis es un proceso potencialmente letal caracterizado por una disfunción orgánica motivada por la respuesta del huésped a la infección y que conlleva a un desequilibrio inmunológico: proinflamatorio e inmunosupresión. Objetivo: Caracterizar el síndrome de respuesta inflamatoria sistémica en cuidados intensivos pediátricos. Métodos: Investigación descriptiva transversal realizada en el Hospital Pediátrico Docente "Pepe Portilla" de Pinar del Río durante el periodo 2015-2018. La muestra quedó constituida por todos los pacientes que ingresaron en cuidados intensivos pediátricos del citado hospital con diagnóstico de síndrome de respuesta inflamatoria sistémica de causa infecciosa o no. Se revisaron las historias clínicas y se elaboró un modelo de recogida de datos en correspondencia con el modelo 241-485-02 del sistema de información del síndrome de respuesta inflamatoria sistémica. Resultados: Hubo un predominio de la afección en pacientes con edades entre 1-4 años 122 (44 %). casos Se recibieron en estadio de sepsis 169 (61 %) pacientes El mayor número de casos, 70,4 % tuvo origen extrahospitalario. La neumonía como causa, se diagnosticó en 52 % de los pacientes. En los pacientes con estadios avanzados 17 (70,9 %) casos fue superior el número de defunciones. Conclusiones: La sepsis continúa siendo un importante problema de salud. Es necesario el ingreso precoz en las unidades de cuidados intensivos pediátricos para lograr una atención integral de estos pacientes.

Introduction: Sepsis is a potentially lethal process characterized by an organ dysfunction motivated by the host's response to infection and leading to an immune, pro-inflammatory and immunosuppression imbalance. Objective: To characterize systemic inflammatory response syndrome in pediatric intensive care units. Methods: Cross-sectional descriptive research carried out at "Pepe Portilla" Pediatric Teaching Hospital in Pinar del Río during the period 2015-2018. The sample consisted of all patients admitted in the pediatric intensive care unit at the aforementioned hospital with a diagnosis of systemic inflammatory response syndrome of infectious or non-infectious cause. The medical records were reviewed and a data collection model was developed in correspondence with model 241-485-02 of the systemic inflammatory response syndrome information system. Results: There was a predominance of the condition in patients aged between 1-4 years, 122 cases (44%). 169 (61%) patients were received in sepsis stage. The highest number of cases, 70.4% had out-of-hospital origin. Pneumonia was diagnosed as a cause in 52% of patients. In patients with advanced stages (17 cases (70.9%)), the number of deaths was higher. Conclusions: Sepsis continues to be a major health problem. Early admission to pediatric intensive care units is necessary to achieve comprehensive care for these patients.

Can an End-to-End Telesepsis Solution Improve the Severe Sepsis and Septic Shock Management Bundle-1 Metrics for Sepsis Patients Admitted From the Emergency Department to the Hospital?

Early detection and treatment for sepsis patients are key components to improving sepsis care delivery and increased The Severe Sepsis and Septic Shock Management Bundle (SEP-1) compliance may correlate with improved outcomes. OBJECTIVES: We assessed the impact of implementing a partially automated end-to-end sepsis solution including electronic medical record-linked automated monitoring, early detection, around-the-clock nurse navigators, and teleconsultation, on SEP-1 compliance in patients with primary sepsis, present at admission, admitted through the emergency department (ER). DESIGN SETTING AND PARTICIPANTS: After a "surveillance only" training period between September 3, 2020, and October 5, 2020, the automated end-to-end sepsis solution intervention period occurred from October 6, 2020, to January 1, 2021 in five ERs in an academic health system. Patients who screened positive for greater than or equal to 3 sepsis screening criteria (systemic inflammatory response syndrome, quick Sequential Organ Failure Assessment, pulse oximetry), had evidence of infection and acute organ dysfunction, and were receiving treatment consistent with infection or sepsis were included. MAIN OUTCOMES AND MEASURES: SEP-1 compliance during the "surveillance only" period compared to the intervention period. RESULTS: During the intervention period, 56,713 patients presented to the five ERs; 20,213 (35.6%) met electronic screening criteria for potential sepsis; 1,233 patients had a primary diagnosis of sepsis, present at admission, and were captured by the nurse navigators. Median age of the cohort was 68 years (interquartile range, 57-79 yr); 55.3% were male; 63.5% were White/Caucasian, 26.3% Black/African-American; was 16.7%, and 879 patients (71.3%) were presumed bacterial sepsis, nonviral etiology, and SEP-1 bundle eligible. Nurse navigator real-time classification of this group increased from 51.7% during the "surveillance only" period to 71.8% during the intervention period (p = 0.0002). Five hospital SEP-1 compliance for the period leading into the study period (July 1, 2020-August 31, 2020) was 62% (p < 0.0001), during the "surveillance only" period, it was 68.4% and during the intervention period it was 78.3% (p = 0.002). CONCLUSIONS AND RELEVANCE: During an 11-week period of sepsis screening, monitoring, and teleconsultation in 5 EDs, SEP-1 compliance improved significantly compared with institutional SEP-1 reporting metrics and to a "surveillance only" training period.

Infecciones graves de huesos, articulaciones y tejidos blandos adquiridas en la comunidad / Severe community-acquired bone, joint, and soft tissue infections

Introducción: Las infecciones de huesos, articulaciones y partes blandas, no solo han tenido una incidencia creciente en los últimos años en el Hospital Pediátrico Universitario Paquito González Cueto de Cienfuegos, sino también una evolución más grave. Objetivo: Describir aspectos clínicos y epidemiológicos de las infecciones graves de tejidos blandos, huesos y articulaciones. Métodos: Se revisó la base de datos computadorizada del Departamento de Estadística del Hospital Pediátrico Paquito González, para identificar todos los egresos de la Unidad de Cuidados Intensivos Pediátricos, con diagnóstico de celulitis o absceso de tejidos blandos, fascitis, miositis, osteomielitis, sepsis severa y shock séptico, en el periodo de enero de 2009 a diciembre de 2019. Se estudiaron las siguientes variables: localización de la infección de piel y tejidos blandos, grupo de edad, año del egreso y sitio de origen de la sepsis. Resultados: No hubo diferencias en la incidencia entre los grupos de edad. La celulitis de los miembros fue la forma clínica más frecuente. Se encontró una incidencia creciente de las infecciones de tejidos blandos. Las infecciones de huesos y articulaciones, representaron el segundo sitio de origen más frecuente de sepsis grave y el shock séptico. Conclusiones: Ha habido un aumento de las infecciones de piel y tejidos blandos que requieren ingreso en la unidad de cuidados intensivos del citado hospital en los últimos 11 años. Estas infecciones de conjunto con las infecciones de huesos y articulaciones, constituyen un problema de salud puesto que provocan sepsis grave y shock séptico con una incidencia significativa(AU)

Introduction: Infections of bones, joints and soft parts have not only had an increasing incidence in recent years at ¨Paquito González Cueto¨ University Pediatric Hospital in Cienfuegos, but also a more serious evolution. Objective: Describe clinical and epidemiological aspects of severe soft tissues, bones and joints infections. Methods: The computerized database of the Department of Statistics of ¨Paquito González¨ Pediatric Hospital was reviewed to identify all discharges from the Pediatric Intensive Care Unit with a diagnosis of cellulite or soft tissue abscess, fasciitis, myositis, osteomyelitis, severe sepsis and septic shock, in the period from January 2009 to December 2019. The following variables were studied: location of skin and soft tissue infection, age group, year of discharge, and sepsis origin location. Results: There were no differences in the incidence between age groups. Limb cellulite was the most common clinical form. An increasing incidence of soft tissue infections was found. Bone and joint infections represented the second most frequent origin location of severe sepsis and septic shock. Conclusions: There has been an increase in skin and soft tissue infections that require admission to the intensive care unit of the aforementioned hospital in the last 11 years. These infections, together with bone and joint infections, constitute a health problem since they cause severe sepsis and septic shock with a significant incidence(AU)

Epidemiology of Pediatric Septic Shock.

Sepsis, or dysregulated host response to infection, is considered a worldwide public health problem. It is a major childhood disease both in terms of frequency and severity, and severe sepsis is still considered the main cause of death from infection in childhood. This review provides an overview of the epidemiology of pediatric septic shock. The prevalence of severe sepsis and septic shock among hospitalized children ranges from 1 to 26%. Mortality is high, ranging from 5% in developed countries to up to 35% in developing countries. However, 10 years after the publication of pediatric sepsis definitions, a global perspective on the burden of this disease in childhood is still missing. Major obstacles to a better knowledge of sepsis epidemiology in children are the absence of an adequate disease definition and not having sepsis as a cause of death in the World Health Organization Global Burden of Disease Report, which is one of the most important sources of information for health policies decision-making in the world. Several studies performed in both developed and developing countries have shown that mortality from septic shock is high and is associated with delayed diagnosis, late treatment, and nonadherence to the treatment guidelines. Reducing mortality from sepsis in childhood is a worldwide challenge, especially in developing countries, where the highest number of cases and deaths are recorded and where financial resources are scarce. Many specialists consider that prevention, education, and organization are key to achieve a reduction in the burden of sepsis.

Immature granulocytes index as early marker of sepsis.

INTRODUCTION: Sepsis induces the recruitment of immature neutrophils into the circulation. An immature granulocyte percentage (IG%) count greater than 3% has been shown to be an indicator for the risk of sepsis. The aim of this study was to evaluate the IG% as predictor of sepsis compared to blood culture results and sepsis diagnostic confirmation. METHODS: The study included individuals (n = 301) of both sexes aged ≥18 years who underwent Hospital São Lucas examinations between January and November 2017. For all the patients, IG%, as well as blood culture results, were evaluated. All examinations were obtained from Clinical Laboratory database. Data were analyzed through the SPSS program version 18.0. RESULTS: There was statistical association between blood culture and IG% results (P = 0.009) and between sepsis confirmation and IG% on Pearson chi-square test (P < 0.001). An IG% cutoff point of 2.0% was able to exclude sepsis based on clinical diagnosis with a specificity of 90.9% and a sensitivity of 38.5%. The cutoff value in ROC analyses of IG% based on blood culture results was 0.3% and 0.4% based on clinical diagnosis. CONCLUSION: Our study demonstrated that IG% <2.0% are helpful on the exclusion of sepsis diagnosis with a very high specificity (90.9%). The IG% is a useful additional marker for sepsis diagnosis allowing the early initiation of therapy and better possibilities of recovery.

Survival analysis of patients with sepsis in Brazil

Abstract INTRODUCTION: This study aimed to analyze the survival of septic patients and to assess prognostic factors. METHODS: Patients with sepsis, severe sepsis, and septic shock were followed up and clinical and laboratory data were collected. The sepsis-related organ failure assessment (SOFA) score was calculated. RESULTS: The overall 30-day survival rates of patients with sepsis, severe sepsis, and septic shock were 86.3%, 72.5%, and 20%, respectively. Mortality was related to old age, septic shock, coagulopathy, lactate level, and high SOFA score among other factors. CONCLUSIONS: Identification of prognostic variables may reduce sepsis-related mortality.

[Utilidad del índice de choque para predecir la mortalidad en pacientes pediátricos con sepsis grave o choque séptico]. / Shock index utility to predict mortality in pediatric patients with septic shock or severe sepsis.

Introducción: La sepsis en pediatría es la principal causa de muerte hospitalaria. Se han intentado crear herramientas que faciliten su identificación, como el índice de choque (IC), definido como el cociente entre frecuencia cardíaca y tensión arterial sistólica. El objetivo de este trabajo fue identificar el mejor momento del IC para predecir la mortalidad en pacientes pediátricos con sepsis grave y choque séptico. Métodos: Cohorte retrospectiva con 165 pacientes pediátricos que desarrollaron sepsis grave y choque séptico en la Unidad de Terapia Intensiva Pediatrica. Se calculó el IC al diagnóstico (IC0), a las dos, cuatro y seis horas posteriores al mismo (IC2, IC4 e IC6). Se crearon dos grupos según el desenlace (sobrevivientes/muertos). La comparación estadística se realizó con prueba U-Mann Whitney y χ2. Se compararon los factores de riesgo entre los sobrevivientes y muertos, calculando la razón de momios (RM). Resultados: Se comparó el valor del IC entre grupos; en el grupo de choque séptico, el IC se encontró más elevado en IC4 e IC6 (p = 0.010 y p = 0.005). Se encontró que, en los pacientes muertos, el IC incrementó progresivamente su valor en IC4 e IC6 (p < 0.05). Los valores de IC4 e IC6 elevados incrementaron el riesgo de muerte en los pacientes (IC4, RM: 442.1; IC 95% [intervalo de confianza al 95%]: 54.2-3,601.7; p < 0.001; e IC6, RM: 81,951.3; IC 95%: 427.1-15,700,000; p < 0.001). Conclusiones: La elevación del valor del IC se asocia con mayor mortalidad de la sepsis. El valor de IC6 es el más útil para predecir mortalidad. Background: Pediatric sepsis is considered the main cause of hospital death around the world. Many groups have tried to create tools that facilitate its early identification, as the shock index (SI) defined as the ratio between cardiac frequency and systolic blood pressure. The objective of this study was to determine the utility of SI to predict mortality in pediatric patients with severe sepsis and septic shock. Methods: Retrospective cohort with 165 pediatric patients with severe sepsis or septic shock in the Pediatric Intensive Care Unit. SI was calculated at diagnosis, 2, 4 and 6 hours after (SI2, SI4 and SI6). We divided the population in two groups depending their outcome: survivors and non-survivors. The statistical analysis was performed with U Mann-Whitney and chi squared tests. The risk factors were compared between the survivors and the dead, and we calculated the odds ratio (OR). Results: The median value of SI was compared between groups; in the group of septic shock, SI showed a tendency to remain high in SI4 and SI6 (p = 0.010 and p = 0.005, respectively). Among the survivors and the non-survivors, we found that in the latter, SI was progressively increased in SI4 and SI6 (p < 0.05). High values of SI4 and SI6 increased the risk of death in patients (SI4: OR: 442.1; CI 95% [confidence interval 95%]: 54.2-3,601.7; p < 0.001 and SI6: OR: 81,951.3; CI 95%: 427.1-15,700,000]; p < 0.001). Conclusions: High values of SI are associated with increased mortality. The IS6 value is the most useful to predict mortality.

Staphylococcus aureus resistente a meticilina / Methicillin-resistant Staphylococcus aureus

La incidencia de infecciones causadas por cocos grampositivos ha aumentado considerablemente desde la década del 80 y particularmente durante la del 90. La emergencia y diseminación de microorganismos multirresistentes ocurre tanto en hospitales como en la comunidad, resultado de la interacción de muchos factores ante la presión selectiva para sobrevivir en presencia de los antibióticos usados. El objetivo es describir las características epidemiológicas, clínicas y de laboratorio de los pacientes con infección por Staphylococcus aureus meticillin resistente. Se realizó un estudio descriptivo de serie de casos. Se incluyeron los niños que tenían infección clínica y microbiológicamente documentadas por Staphylococcus aureus meticillin resistente. De 42 pacientes ingresados con infección por S. aureus, en la terapia pediátrica infantil del Hospital Comandante Pinares, en el período comprendido de julio 2012 a octubre del 2015, se seleccionaron 5 pacientes en quienes se aísla por hemocultivo y cultivo de secreciones el Staphylococcus aureus meticillin resistente, corroborado en el Instituto de Medicina Tropical "Pedro Kouri". Los resultados se describen por variables y en distribución de frecuencias. Se instauró tratamiento al 100 % de los pacientes con vancomicina y evolucionaron satisfactoriamente el 80 % de estos. Se presentaron complicaciones relacionadas con el órgano inicialmente afectado y también a distancia. Se cumplieron protocolos de tratamiento para la sepsis severa, el shock séptico y la disfunción múltiple de órganos. Se logró una supervivencia del 80 %. Se concluye que la infección por Staphylococcus aureus meticillin resistente constituye una enfermedad emergente en nuestro medio. La realización de un adecuado estudio de cada caso, determina un mejor manejo terapéutico de esta infección.

The incidence of infections caused by gram-positive cocci has increased considerably since the 1980s and particularly during the 1990s. Emergence and dissemination of multiresistant microorganisms occur in hospitals as well as in the community, as a result of the interaction of many factors in response to the selective pressure to survive in the presence of the antibiotics used. The objective of the study was to describe the epidemiological, clinical and laboratory characteristics of patients infected by methicillin-resistant Staphylococcus aureus. A descriptive study was conducted of a case series. The sample was composed of children with clinically and microbiologically documented infection by methicillin-resistant Staphylococcus aureus. Of 42 patients hospitalized with infection by S. aureus in the pediatric therapy service of Comandante Pinares Hospital from July 2012 to October 2015, five were selected from whom methicillin-resistant Staphylococcus aureus was isolated by blood and secretion culture and confirmed at Pedro Kourí Tropical Medicine Institute. The results are shown per variable and in frequency distributions. All the patients were treated with vancomycin and 80% had a satisfactory evolution. Complications were related to the organ initially affected as well as to distant organs. Treatment protocols for severe sepsis, septic shock and multiple organ dysfunction were complied with. 80% survival was achieved. It is concluded that infection by methicillin-resistant Staphylococcus aureus is an emerging disease in our environment. An appropriate study of each case leads to better therapeutic management of this infection.

Utilidad del índice de choque para predecir la mortalidad en pacientes pediátricos con sepsis grave o choque séptico / Shock index utility to predict mortality in pediatric patients with septic shock or severe sepsis

Resumen Introducción: La sepsis en pediatría es la principal causa de muerte hospitalaria. Se han intentado crear herramientas que faciliten su identificación, como el índice de choque (IC), definido como el cociente entre frecuencia cardíaca y tensión arterial sistólica. El objetivo de este trabajo fue identificar el mejor momento del IC para predecir la mortalidad en pacientes pediátricos con sepsis grave y choque séptico. Métodos: Cohorte retrospectiva con 165 pacientes pediátricos que desarrollaron sepsis grave y choque séptico en la Unidad de Terapia Intensiva Pediatrica. Se calculó el IC al diagnóstico (IC0), a las dos, cuatro y seis horas posteriores al mismo (IC2, IC4 e IC6). Se crearon dos grupos según el desenlace (sobrevivientes/muertos). La comparación estadística se realizó con prueba U-Mann Whitney y χ2. Se compararon los factores de riesgo entre los sobrevivientes y muertos, calculando la razón de momios (RM). Resultados: Se comparó el valor del IC entre grupos; en el grupo de choque séptico, el IC se encontró más elevado en IC4 e IC6 (p = 0.010 y p = 0.005). Se encontró que, en los pacientes muertos, el IC incrementó progresivamente su valor en IC4 e IC6 (p < 0.05). Los valores de IC4 e IC6 elevados incrementaron el riesgo de muerte en los pacientes (IC4, RM: 442.1; IC 95% [intervalo de confianza al 95%]: 54.2-3,601.7; p < 0.001; e IC6, RM: 81,951.3; IC 95%: 427.1-15,700,000; p < 0.001). Conclusiones: La elevación del valor del IC se asocia con mayor mortalidad de la sepsis. El valor de IC6 es el más útil para predecir mortalidad.

Abstract Background: Pediatric sepsis is considered the main cause of hospital death around the world. Many groups have tried to create tools that facilitate its early identification, as the shock index (SI) defined as the ratio between cardiac frequency and systolic blood pressure. The objective of this study was to determine the utility of SI to predict mortality in pediatric patients with severe sepsis and septic shock. Methods: Retrospective cohort with 165 pediatric patients with severe sepsis or septic shock in the Pediatric Intensive Care Unit. SI was calculated at diagnosis, 2, 4 and 6 hours after (SI2, SI4 and SI6). We divided the population in two groups depending their outcome: survivors and non-survivors. The statistical analysis was performed with U Mann-Whitney and chi squared tests. The risk factors were compared between the survivors and the dead, and we calculated the odds ratio (OR). Results: The median value of SI was compared between groups; in the group of septic shock, SI showed a tendency to remain high in SI4 and SI6 (p = 0.010 and p = 0.005, respectively). Among the survivors and the non-survivors, we found that in the latter, SI was progressively increased in SI4 and SI6 (p < 0.05). High values of SI4 and SI6 increased the risk of death in patients (SI4: OR: 442.1; CI 95% [confidence interval 95%]: 54.2-3,601.7; p < 0.001 and SI6: OR: 81,951.3; CI 95%: 427.1-15,700,000]; p < 0.001). Conclusions: High values of SI are associated with increased mortality. The IS6 value is the most useful to predict mortality.

Sepsis grave en la unidad de terapia intensiva del Instituto de Medicina Tropical Pedro Kourí / Severe sepsis in the intensive care unit of Pedro Kourí Tropical Medicine Institute

Introducción: La última década muestra aumento de la prevalencia de sepsis grave por microorganismos multidrogorresistentes, lo que representa una alerta para los gobiernos y sistemas de salud en el manejo de la multirresistencia. Objetivo: Identificar los microorganismos causantes de sepsis grave y sensibilidad a los antimicrobianos, así como relacionar los niveles de proteína C reactiva con la sepsis grave. Métodos: Estudio descriptivo de corte transversal que incluyó a 30 pacientes con diagnóstico de sepsis grave ingresados en la Unidad de Cuidados Intensivos del hospital del Instituto de Medicina Tropical Pedro Kourí durante el 2016. Resultados: Las neumonías fueron el foco primario dominante (43,3 por ciento), y las infecciones por gérmenes gramnegativos las más frecuentes. Los aislamientos microbiológicos (pseudomonas y acinetobacter baumannii) mostraron multidrogorresistencia que incluye a carbapenémicos y colistina, lo que sugiere utilización de forma indiscriminada y no justificada de antibióticos en pacientes inmunodeprimidos VIH. Se demostró asociación entre la infección por gérmenes gramnegativos y títulos elevados de proteína C reactiva con el desarrollo de sepsis grave y evolución desfavorable. El aumento de las supervivencias de los pacientes VIH con las terapias antirretrovilales, demostraron la predisposición de estos enfermos a infecciones por gérmenes multidrogorresistentes. Conclusiones: Los pacientes VIH tienen predisposición a infecciones por microorganismos multidrogorresistentes, la proteína C reactiva es útil como marcador de sepsis grave en estos enfermos. Estudios de este tipo demuestran a los sistemas de salud la necesidad trazar estrategias a corto plazo para el manejo de pacientes con VIH y sepsis grave por microorganismos multidrogorresistentes(AU)

Introduction: The last decade shows an increase in the prevalence of severe sepsis by multidrug resistant microorganisms which represent an alert for governments and health systems in relation with multiresistance management. Objective: To identify the microorganisms that cause severe sepsis and sensitivity to the antimicrobials, as well as to relate the levels of C-reactive protein with the severe sepsis. Methods: A descriptive, cross-sectional study was carried out involving 30 patients diagnosed with severe sepsis and admitted in 2016 to the Intensive Care Unit of the Hospital in Pedro Kourí Tropical Medicine Institute. Results: The prevalence of severe sepsis was 24.8 percent mainly in male patients (71.1 percent) and with ages from 41 to 50 years old (40.0 percent). Pneumonias were the predominant primary source (43.3 percent), and infections caused by negative Gram germs were the most frequent. Microbiological isolates (pseudomonas and acinetobacterbaumannii) showed multidrug resistance including carbapenems and colistin, which suggests an indiscriminate and non-justified use of antibiotics in HIV inmunodepressed patients. It was demonstrated a relation between infection by negative Gram germs and elevated levels of C-reactive protein with the development of severe sepsis and unfavorable evolution. The increasing survival rate in patients with HIV showed a predisposition of them to infections caused by multidrug resistant germs. Conclusions: HIV positive patients have a predisposition to infections caused by multidrug resistant microorganisms. C-reactive protein is useful as a marker of severe sepsis in this kind of patients. Studies of this type show to health systems the need to develop strategies in short term for managing HIV patients and the severe sepsis caused by multidrug resistant microorganisms(AU)

Sepsis grave en la unidad de terapia intensiva del Instituto de Medicina Tropical Pedro Kourí / Severe sepsis in the intensive care unit of Pedro Kourí Tropical Medicine Institute

Introducción: La última década muestra aumento de la prevalencia de sepsis grave por microorganismos multidrogorresistentes, lo que representa una alerta para los gobiernos y sistemas de salud en el manejo de la multirresistencia. Objetivo: Identificar los microorganismos causantes de sepsis grave y sensibilidad a los antimicrobianos, así como relacionar los niveles de proteína C reactiva con la sepsis grave. Métodos: Estudio descriptivo de corte transversal que incluyó a 30 pacientes con diagnóstico de sepsis grave ingresados en la Unidad de Cuidados Intensivos del hospital del Instituto de Medicina Tropical Pedro Kourí durante el 2016. Resultados: Las neumonías fueron el foco primario dominante (43,3 por ciento), y las infecciones por gérmenes gramnegativos las más frecuentes. Los aislamientos microbiológicos (pseudomonas y acinetobacter baumannii) mostraron multidrogorresistencia que incluye a carbapenémicos y colistina, lo que sugiere utilización de forma indiscriminada y no justificada de antibióticos en pacientes inmunodeprimidos VIH. Se demostró asociación entre la infección por gérmenes gramnegativos y títulos elevados de proteína C reactiva con el desarrollo de sepsis grave y evolución desfavorable. El aumento de las supervivencias de los pacientes VIH con las terapias antirretrovilales, demostraron la predisposición de estos enfermos a infecciones por gérmenes multidrogorresistentes. Conclusiones: Los pacientes VIH tienen predisposición a infecciones por microorganismos multidrogorresistentes, la proteína C reactiva es útil como marcador de sepsis grave en estos enfermos. Estudios de este tipo demuestran a los sistemas de salud la necesidad trazar estrategias a corto plazo para el manejo de pacientes con VIH y sepsis grave por microorganismos multidrogorresistentes(AU)

Introduction: The last decade shows an increase in the prevalence of severe sepsis by multidrug resistant microorganisms which represent an alert for governments and health systems in relation with multiresistance management. Objective: To identify the microorganisms that cause severe sepsis and sensitivity to the antimicrobials, as well as to relate the levels of C-reactive protein with the severe sepsis. Methods: A descriptive, cross-sectional study was carried out involving 30 patients diagnosed with severe sepsis and admitted in 2016 to the Intensive Care Unit of the Hospital in Pedro Kourí Tropical Medicine Institute. Results: The prevalence of severe sepsis was 24.8 percent mainly in male patients (71.1 percent) and with ages from 41 to 50 years old (40.0 percent). Pneumonias were the predominant primary source (43.3 percent), and infections caused by negative Gram germs were the most frequent. Microbiological isolates (pseudomonas and acinetobacterbaumannii) showed multidrug resistance including carbapenems and colistin, which suggests an indiscriminate and non-justified use of antibiotics in HIV inmunodepressed patients. It was demonstrated a relation between infection by negative Gram germs and elevated levels of C-reactive protein with the development of severe sepsis and unfavorable evolution. The increasing survival rate in patients with HIV showed a predisposition of them to infections caused by multidrug resistant germs. Conclusions: HIV positive patients have a predisposition to infections caused by multidrug resistant microorganisms. C-reactive protein is useful as a marker of severe sepsis in this kind of patients. Studies of this type show to health systems the need to develop strategies in short term for managing HIV patients and the severe sepsis caused by multidrug resistant microorganisms(AU)

Administração seriada de salina hipertônica 7, 5% na terapia para sepse grave decorrente da síndrome da diarreia hemorrágica aguda em cães / Serial administration of 7. 5% hypertonic saline solution in the therapy of severe sepsis due to acute hemorrhagic diarrhea syndrome in dogs

Na clínica de animais de companhia é frequente cães com síndrome da diarreia hemorrágica aguda associada a quadros de sepse, o que acarreta alta mortalidade. Nesse contexto, objetivou-se, em um ensaio clínico controlado aleatorizado de centro único, estudar os efeitos tardios da solução salina hipertônica a 7,5% em aplicações seriadas, sobre variáveis hemodinâmicas, clínicas e laboratoriais em cães com quadro de sepse grave decorrente desta síndrome. Para tal, 12 cães foram aleatoriamente distribuídos em dois grupos de igual número, sendo um controle (CON) e o outro, solução salina hipertônica 7,5% (SSH). Variáveis clínicas e laboratoriais foram avaliadas imediatamente após a admissão do paciente (T0), 24 (T24), 48 (T48) e 72 (T72) horas após a admissão. O grupo SSH recebeu Ringer com lactato, antibioticoterapia, analgésico e SSH 7,5% em bolus (5mL kg-1 em 4 minutos) no T24 e no T48. O grupo CON recebeu a mesma terapia acima, porém ao invés da utilização de SSH a 7,5%, administrou-se bolus de solução de Ringer lactato na mesma dose e tempos utilizado. As avaliações em cada tempo foram realizadas anteriormente à administração dos bolus, nos dois grupos. Avaliaram-se hemograma completo e as variáveis clínicas (escala AVDN, grau de desidratação, frequência respiratória e temperatura retal), frequência cardíaca (FC), pressão arterial sistólica (PAS). Os dados paramétricos foram avaliados pelos testes Student Newman Keuls e teste t de Student, e os não paramétricos pelo teste de Friedman e Mann Whitney, com nível de significância de P≥0,05. Nas variáveis clínicas estudadas não se observou diferença entre os grupos e entre os momentos avaliados. Observou-se diferença significativa no grupo SSH no T72, com elevação da PAS e redução da FC, fato não observado no grupo CON, onde esses parâmetros não se alteraram. O hematócrito e a concentração de hemoglobina diminuíram em ambos os grupos com o tempo. As contagens dos leucócitos totais e dos monócitos apresentaram uma elevação significativa no grupo SSH, estando os leucócitos dentro da faixa de normalidade no T72. Não houve diferenças significativas em relação aos neutrófilos segmentados, porém no grupo SSH verificou-se aumento de 9,5 vezes no T72 comparado com o T24 (P=0,09), enquanto que este aumento foi de apenas 2,5 vezes no grupo CON (P=0,30). Observou-se ainda redução nas contagens de plaquetas e na concentração de globulinas no grupo COM, enquanto essas variáveis se mantiveram estáveis no grupo SSH. Conclui-se que a administração seriada de SSH 7,5% se mostrou promissora no tratamento de cães com síndrome da diarreia hemorrágica aguda, pois auxilia na estabilização dos leucócitos, plaquetas e globulinas de cães com sepse grave decorrente da síndrome da diarreia hemorrágica aguda.(AU)

The association between acute hemorrhagic diarrhea syndrome and sepsis is frequent in dogs and causes high mortality. In this context we investigated in a randomized single-center controlled trial the late effects of 7.5% hypertonic saline solution in serial applications on hemodynamic, clinical and laboratory variables in dogs with severe sepsis due to the syndrome. Twelve dogs were randomly distributed into two groups of equal numbers, control (CON) and 7.5% hypertonic saline solution (SSH). Clinical and laboratory variables were evaluated immediately after admission of patients (T0), 24 (T24), 48 (T48) and 72 (T72) hours after the admission. The SSH group received Ringer with lactate, antibiotic therapy, analgesic and 5mL/kg-1 bolus of 7.5% SSH over 4 minutes on T24 and T48. The CON group received the same therapy, but instead of 7.5% SSH, Ringer with lactate bolus was given at the same dosis and times. All evaluations were performed prior to the administration of the bolus in both groups. Data collection included complete blood count and clinical variables (AVDN scale, degree of dehydration, respiratory rate and rectal temperature), heart rate (HR) and systolic blood pressure (SBP). Parametric data were evaluated by the Student Newman Keuls and Student t tests, and the nonparametric ones by the Friedman and Mann Whitney test, with a significance level of 0.05. There were no significant differences between the groups and moments in clinical variables. Nevertheless, the SSH group presented a significant elevation of SBP and HR reduction at T72. Hematocrit and hemoglobin concentration decreased in both groups over time. Total leukocyte and monocyte counts showed a significant elevation in the SSH group, however the leukocytes were within the normal range at T72. There were no significant differences in the segmental neutrophils, but a 9.5-fold increase in T72 compared to T24 (P=0.09) in the SSH group was observed, whereas this increase was only 2.5-fold in the CON group (P=0.30). A decrease in platelet counts and globulin concentration was observed in the CON group, while these variables remained stable in the SSH group. In conclusion, serial administration of 7.5% SSH is promising in the therapy of dogs with acute hemorrhagic diarrhea syndrome, since it assists in the stabilization of leukocytes, platelets and globulins in dogs with severe sepsis due to this syndrome.(AU)

Administração seriada de salina hipertônica 7, 5% na terapia para sepse grave decorrente da síndrome da diarreia hemorrágica aguda em cães / Serial administration of 7. 5% hypertonic saline solution in the therapy of severe sepsis due to acute hemorrhagic diarrhea syndrome in dogs

Na clínica de animais de companhia é frequente cães com síndrome da diarreia hemorrágica aguda associada a quadros de sepse, o que acarreta alta mortalidade. Nesse contexto, objetivou-se, em um ensaio clínico controlado aleatorizado de centro único, estudar os efeitos tardios da solução salina hipertônica a 7,5% em aplicações seriadas, sobre variáveis hemodinâmicas, clínicas e laboratoriais em cães com quadro de sepse grave decorrente desta síndrome. Para tal, 12 cães foram aleatoriamente distribuídos em dois grupos de igual número, sendo um controle (CON) e o outro, solução salina hipertônica 7,5% (SSH). Variáveis clínicas e laboratoriais foram avaliadas imediatamente após a admissão do paciente (T0), 24 (T24), 48 (T48) e 72 (T72) horas após a admissão. O grupo SSH recebeu Ringer com lactato, antibioticoterapia, analgésico e SSH 7,5% em bolus (5mL kg-1 em 4 minutos) no T24 e no T48. O grupo CON recebeu a mesma terapia acima, porém ao invés da utilização de SSH a 7,5%, administrou-se bolus de solução de Ringer lactato na mesma dose e tempos utilizado. As avaliações em cada tempo foram realizadas anteriormente à administração dos bolus, nos dois grupos. Avaliaram-se hemograma completo e as variáveis clínicas (escala AVDN, grau de desidratação, frequência respiratória e temperatura retal), frequência cardíaca (FC), pressão arterial sistólica (PAS). Os dados paramétricos foram avaliados pelos testes Student Newman Keuls e teste t de Student, e os não paramétricos pelo teste de Friedman e Mann Whitney, com nível de significância de P≥0,05. Nas variáveis clínicas estudadas não se observou diferença entre os grupos e entre os momentos avaliados. Observou-se diferença significativa no grupo SSH no T72, com elevação da PAS e redução da FC, fato não observado no grupo CON, onde esses parâmetros não se alteraram. O hematócrito e a concentração de hemoglobina diminuíram em ambos os grupos com o tempo. As contagens dos leucócitos totais e dos monócitos apresentaram uma elevação significativa no grupo SSH, estando os leucócitos dentro da faixa de normalidade no T72. Não houve diferenças significativas em relação aos neutrófilos segmentados, porém no grupo SSH verificou-se aumento de 9,5 vezes no T72 comparado com o T24 (P=0,09), enquanto que este aumento foi de apenas 2,5 vezes no grupo CON (P=0,30). Observou-se ainda redução nas contagens de plaquetas e na concentração de globulinas no grupo COM, enquanto essas variáveis se mantiveram estáveis no grupo SSH. Conclui-se que a administração seriada de SSH 7,5% se mostrou promissora no tratamento de cães com síndrome da diarreia hemorrágica aguda, pois auxilia na estabilização dos leucócitos, plaquetas e globulinas de cães com sepse grave decorrente da síndrome da diarreia hemorrágica aguda.(AU)

The association between acute hemorrhagic diarrhea syndrome and sepsis is frequent in dogs and causes high mortality. In this context we investigated in a randomized single-center controlled trial the late effects of 7.5% hypertonic saline solution in serial applications on hemodynamic, clinical and laboratory variables in dogs with severe sepsis due to the syndrome. Twelve dogs were randomly distributed into two groups of equal numbers, control (CON) and 7.5% hypertonic saline solution (SSH). Clinical and laboratory variables were evaluated immediately after admission of patients (T0), 24 (T24), 48 (T48) and 72 (T72) hours after the admission. The SSH group received Ringer with lactate, antibiotic therapy, analgesic and 5mL/kg-1 bolus of 7.5% SSH over 4 minutes on T24 and T48. The CON group received the same therapy, but instead of 7.5% SSH, Ringer with lactate bolus was given at the same dosis and times. All evaluations were performed prior to the administration of the bolus in both groups. Data collection included complete blood count and clinical variables (AVDN scale, degree of dehydration, respiratory rate and rectal temperature), heart rate (HR) and systolic blood pressure (SBP). Parametric data were evaluated by the Student Newman Keuls and Student t tests, and the nonparametric ones by the Friedman and Mann Whitney test, with a significance level of 0.05. There were no significant differences between the groups and moments in clinical variables. Nevertheless, the SSH group presented a significant elevation of SBP and HR reduction at T72. Hematocrit and hemoglobin concentration decreased in both groups over time. Total leukocyte and monocyte counts showed a significant elevation in the SSH group, however the leukocytes were within the normal range at T72. There were no significant differences in the segmental neutrophils, but a 9.5-fold increase in T72 compared to T24 (P=0.09) in the SSH group was observed, whereas this increase was only 2.5-fold in the CON group (P=0.30). A decrease in platelet counts and globulin concentration was observed in the CON group, while these variables remained stable in the SSH group. In conclusion, serial administration of 7.5% SSH is promising in the therapy of dogs with acute hemorrhagic diarrhea syndrome, since it assists in the stabilization of leukocytes, platelets and globulins in dogs with severe sepsis due to this syndrome.(AU)

Administração seriada de salina hipertônica 7,5% na terapia para sepse grave decorrente da síndrome da diarreia hemorrágica aguda em cães

ABSTRACT: The association between acute hemorrhagic diarrhea syndrome and sepsis is frequent in dogs and causes high mortality. In this context we investigated in a randomized single-center controlled trial the late effects of 7.5% hypertonic saline solution in serial applications on hemodynamic, clinical and laboratory variables in dogs with severe sepsis due to the syndrome. Twelve dogs were randomly distributed into two groups of equal numbers, control (CON) and 7.5% hypertonic saline solution (SSH). Clinical and laboratory variables were evaluated immediately after admission of patients (T0), 24 (T24), 48 (T48) and 72 (T72) hours after the admission. The SSH group received Ringer with lactate, antibiotic therapy, analgesic and 5mL/kg-1 bolus of 7.5% SSH over 4 minutes on T24 and T48. The CON group received the same therapy, but instead of 7.5% SSH, Ringer with lactate bolus was given at the same dosis and times. All evaluations were performed prior to the administration of the bolus in both groups. Data collection included complete blood count and clinical variables (AVDN scale, degree of dehydration, respiratory rate and rectal temperature), heart rate (HR) and systolic blood pressure (SBP). Parametric data were evaluated by the Student Newman Keuls and Student t tests, and the nonparametric ones by the Friedman and Mann Whitney test, with a significance level of 0.05. There were no significant differences between the groups and moments in clinical variables. Nevertheless, the SSH group presented a significant elevation of SBP and HR reduction at T72. Hematocrit and hemoglobin concentration decreased in both groups over time. Total leukocyte and monocyte counts showed a significant elevation in the SSH group, however the leukocytes were within the normal range at T72. There were no significant differences in the segmental neutrophils, but a 9.5-fold increase in T72 compared to T24 (P=0.09) in the SSH group was observed, whereas this increase was only 2.5-fold in the CON group (P=0.30). A decrease in platelet counts and globulin concentration was observed in the CON group, while these variables remained stable in the SSH group. In conclusion, serial administration of 7.5% SSH is promising in the therapy of dogs with acute hemorrhagic diarrhea syndrome, since it assists in the stabilization of leukocytes, platelets and globulins in dogs with severe sepsis due to this syndrome.

RESUMO: Na clínica de animais de companhia é frequente cães com síndrome da diarreia hemorrágica aguda associada a quadros de sepse, o que acarreta alta mortalidade. Nesse contexto, objetivou-se, em um ensaio clínico controlado aleatorizado de centro único, estudar os efeitos tardios da solução salina hipertônica a 7,5% em aplicações seriadas, sobre variáveis hemodinâmicas, clínicas e laboratoriais em cães com quadro de sepse grave decorrente desta síndrome. Para tal, 12 cães foram aleatoriamente distribuídos em dois grupos de igual número, sendo um controle (CON) e o outro, solução salina hipertônica 7,5% (SSH). Variáveis clínicas e laboratoriais foram avaliadas imediatamente após a admissão do paciente (T0), 24 (T24), 48 (T48) e 72 (T72) horas após a admissão. O grupo SSH recebeu Ringer com lactato, antibioticoterapia, analgésico e SSH 7,5% em bolus (5mL kg-1 em 4 minutos) no T24 e no T48. O grupo CON recebeu a mesma terapia acima, porém ao invés da utilização de SSH a 7,5%, administrou-se bolus de solução de Ringer lactato na mesma dose e tempos utilizado. As avaliações em cada tempo foram realizadas anteriormente à administração dos bolus, nos dois grupos. Avaliaram-se hemograma completo e as variáveis clínicas (escala AVDN, grau de desidratação, frequência respiratória e temperatura retal), frequência cardíaca (FC), pressão arterial sistólica (PAS). Os dados paramétricos foram avaliados pelos testes Student Newman Keuls e teste t de Student, e os não paramétricos pelo teste de Friedman e Mann Whitney, com nível de significância de P0,05. Nas variáveis clínicas estudadas não se observou diferença entre os grupos e entre os momentos avaliados. Observou-se diferença significativa no grupo SSH no T72, com elevação da PAS e redução da FC, fato não observado no grupo CON, onde esses parâmetros não se alteraram. O hematócrito e a concentração de hemoglobina diminuíram em ambos os grupos com o tempo. As contagens dos leucócitos totais e dos monócitos apresentaram uma elevação significativa no grupo SSH, estando os leucócitos dentro da faixa de normalidade no T72. Não houve diferenças significativas em relação aos neutrófilos segmentados, porém no grupo SSH verificou-se aumento de 9,5 vezes no T72 comparado com o T24 (P=0,09), enquanto que este aumento foi de apenas 2,5 vezes no grupo CON (P=0,30). Observou-se ainda redução nas contagens de plaquetas e na concentração de globulinas no grupo COM, enquanto essas variáveis se mantiveram estáveis no grupo SSH. Conclui-se que a administração seriada de SSH 7,5% se mostrou promissora no tratamento de cães com síndrome da diarreia hemorrágica aguda, pois auxilia na estabilização dos leucócitos, plaquetas e globulinas de cães com sepse grave decorrente da síndrome da diarreia hemorrágica aguda.

Hospitalizaciones por neumonía adquirida en la comunidad / Hospitalizations for community-acquired pneumonia

Introducción: Streptoccocus pneumoniae es la causa más frecuente de neumonía bacteriana adquirida en la comunidad en la edad pediátrica. Objetivo: estimar la proporción de casos hospitalizados y defunciones por neumonía, así como describir la utilización de servicios de atención al paciente grave en niños con neumonía y sepsis. Métodos: se realizó un estudio retrospectivo de series de casos de niños entre 1 mes a 18 años, 2002-2013, así como datos de ingreso por neumonía (confirmada radiológicamente) y sepsis, en la Unidad de Terapia Intensiva 2011-2013, del Hospital Pediátrico Centro Habana. Resultados: se registraron un total de 5 672 ingresos por neumonía, para una media de 469 casos anuales, más frecuente en varones (53,2 por ciento) y niños entre 1 a 4 años (55,1 por ciento). Se registraron 14 fallecidos (0,25 por ciento del total), de los cuales 9 fueron del sexo masculino (64,3 por ciento). Entre 2011-2013, el 6 a 9 por ciento de los niños con neumonía requirieron ingreso en unidades de atención al grave, con predominio también de preescolares. Conclusiones: los datos obtenidos pueden aportar evidencia indirecta de la magnitud de la enfermedad neumocócica en un hospital pediátrico(AU)

Introduction: Streptococcus pneumoniae is the most common cause of community-acquired bacterial pneumonia at pediatric ages. Objective: to estimate the ratio of hospitalized cases and deaths of pneumonia as well as to describe the use of services to severely-ill patients in children with pneumonia and sepsis. Methods: retrospective case-series study performed in children aged one to 18 years from 2002 to 2013 and of hospitalization data for pneumonia (X ray-confirmed) and sepsis in the intensive care unit from 2011 to 2013 in Centro Habana pediatric hospital. Results: a total number of 5 672 admissions for pneumonia were registered, for a mean of 469 cases yearly, more frequent in males (53.2 percent) and children aged one to four years (55.1 percent). There were 14 deaths (0.25 percent of total number) and nine of them were males (64.3 percent). From 2011 to 2013, six to nine percent of children with pneumonia required admission to the severely-ill patient care unit with predominance of pre-school children. Conclusions: the collected data may provide indirect evidence for analysis of the magnitude of pneumococcal disease in a pediatric hospital(AU)

Severe Sepsis and Septic Shock Associated with Chikungunya Virus Infection, Guadeloupe, 2014.

During a 2014 outbreak, 450 patients with confirmed chikungunya virus infection were admitted to the University Hospital of Pointe-à-Pitre, Guadeloupe. Of these, 110 were nonpregnant adults; 42 had severe disease, and of those, 25 had severe sepsis or septic shock and 12 died. Severe sepsis may be a rare complication of chikungunya virus infection.

Improving Outcomes in Patients With Sepsis.

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.

Pacientes con infección por VIH/SIDA en una Unidad de Pacientes Críticos: La experiencia de un hospital general en un país en desarrollo / HIV/AIDS patients in a Critical Care Unit: The experience of a general hospital in a developing country

Introduction and aims: Despite general availability of HAART in Chile, admissions of HIV/AIDS patients to Intensive-Intermediate Care Units (IICU) are still happening, and a characterization of patient's profile, mortality and potentially avoidable admissions is necessary. Methods: Observational retrospective study in one general hospital in Chile of HIV/AIDS patients admitted to IICU during 9 years. Results: During 2005-2013, 32 patients were admitted to IICU, with 87,5% in AIDS stage, only 53,1% knew his/her condition, 43,8% were receiving HAART and 16.6% chemoprophylaxis for opportunistic infections, A CD4 count < 200/µL was registered in 75,9% of patients. Most admissions were driven by infectious conditions (84,4%) and 48,1% developed septic shock, IICU hospitalizations were motivated by respiratory failure, neurologic compromise, sepsis or a mixture of them (87,5%), By univariate analysis, admissions by respiratory failure were associated to no HAART, oral candidiasis or CD4 < 250/µL (p < 0.01). Eight patients died during their first hospitalization (25%) and other 5 in the following month after discharge. Death during hospitalization was significantly associated to vasoactive drug use ≥ 7 days (OR 16.5; IC95 2.1-128 p < 0.01). In multivariate analysis, APACHE score ≥ 18 was associated with death during hospitalization of after discharge (OR 3,3 IC95 1,1-10; p < 0,05), Four patients (12,5%) had potentially avoidable admissions. Conclusions: Despite HAART availability in Chile, hospitalizations of patients with HIV/AIDS are still happening, affecting those that either are unaware of his/her condition, are not receiving HAART and/or chemoprophylaxis. These admissions generate premature deaths and happen even after discharge in severely ill patients.

Antecedentes y Objetivos: A pesar de la disponibilidad de la terapia viral de gran actividad (TARGA) en Chile el ingreso de pacientes con infección por VIH/SIDA a la Unidad de Pacientes Críticos (UPC) siguen ocurriendo. Se necesita mayor información en Chile sobre el perfil de estos pacientes, su mortalidad y el porcentaje de ingresos evitables. Método: Estudio observacional retrospectivo de pacientes adultos que ingresaron a la UPC en un hospital general durante 9 años. Resultados: En el período 2005-2013 se identificaron 32 pacientes que ingresaron a UPC. El 87,5% estaba en etapa SIDA al ingreso, 53,1% sabía su diagnóstico, sólo 43,8% recibía terapia TARGA y 16,6% quimioprofilaxis. Un 75,9% tenía un recuento CD4 < 200/µL. La mayoría de los ingresos fue por una causa infecciosa (84,4%) y 48,1% presentaron shock séptico. Por sistemas, los ingresos a UPC fueron liderados por falla respiratoria, compromiso neurológico, sepsis o una mezcla de ellos (87,5%). Por análisis univariado, el ingreso por falla respiratoria se asoció a ausencia de HAART, candidiasis oral o un recuento CD4 < 250/µL (p < 0,01). Ocho pacientes fallecieron en la primera hospitalización (25%) y otros cinco en los meses siguientes al alta. El desenlace fatal en el hospital estuvo significativamente asociado al uso de fármacos vasoactivos por ≥ 7 días (OR 16,5; IC 95 2,1-128 p < 0,01). En el análisis multivariado, un score APACHE ≥ 18 se asoció en forma independiente a fallecimiento en el hospital o post alta (OR 3,3 IC 95 1,1-10; p < 0,05). Cuatro pacientes (12,5%), tuvieron hospitalizaciones potencialmente evitables. Conclusiones: Las hospitalizaciones de pacientes con infección VIH a UPC siguen ocurriendo a pesar de la disponibilidad de TARGA en Chile, afectando a pacientes que desconocen su condición, no están en tratamiento o con profilaxis. Estos ingresos generan muertes prematuras, las que ocurren incluso después del alta en los pacientes más graves.

Manifestaciones cutáneas por choque séptico en una adulta / Cutaneous manifestations septic shock in an adult woman

Se describe el caso clínico de una adulta de 33 años de edad con antecedentes de asma bronquial, que fue ingresada en el Hospital General Universitario "Carlos Manuel de Céspedes", en Bayamo (Granma), por choque séptico a causa de una bronconeumonía bacteriana, además de disfunción orgánica y acidosis metabólica sostenida, que requerían el apoyo de drogas vasoactivas a altas dosis. También aparecieron lesiones diseminadas en la piel, principalmente en las áreas distales de las manos y los pies, con coloración violácea y necrosis isquémicas hacia los pulpejos de los dedos. En los hemocultivos se aisló el Staphylococcus aureus, y el tratamiento consistió en sostén hemodinámico, antimicrobianos de amplio espectro, corticoesteroides y curas de las lesiones cutáneas, que incluyó la escisión del tejido necrosado.

The case report of a 33 years adult woman is described with a history of bronchial asthma who was admitted in "Carlos Manuel de Céspedes" University General Hospital in Bayamo (Granma), due to septic shock caused by a bacterial bronchopneumonia, besides organic dysfunction, sustained metabolic acidosis which required high doses of vasoactive drugs. Lesions disseminated in the skin were also present, mainly in the distal areas of hands and feet, violet in colour and ischemic necrosis toward the fleshy part of the fingers. In the blood cultures Staphylococcus aureus was isolated, and the treatment consisted on hemodynamic support, wide spectrum antimicrobials, corticosteroids and cures in the cutaneous lesions that included necrectomy.

Sepsis severa y shock séptico en la Unidad de Cuidados IntensivosPediátrico de Sancti Spíritus / Severe sepsis and septic shock in the Intensive Care Unit of José Martí Pediatric Hospital of Sancti Spíritus

Fundamento: La sepsis severa y el shock séptico constituyen una de las causas de morbilidad y mortalidad en la población pediátrica mundialmente. Se ha observado en los últimos años un incremento de los pacientes que ingresan en estos estadios de la sepsis en la Unidad de Cuidados Intensivos Pediátricos de Sancti Spíritus. Objetivo: Describir las características clínico epidemiológicas de la sepsis severa y el shock séptico en la Unidad de Cuidados Intensivos Pediátricos de Sancti Spíritus del 2005 al 2008. Metodología: Se realizó un estudio descriptivo retrospectivo de pacientes ingresados en la Unidad de Cuidados Intensivos Pediátricos de Sancti Spíritus con sepsis severa y shock séptico en el periodo estudiado, con las variables edad, sexo, factores de riesgo por sepsis, lugar de referencia a la Unidad de Cuidados Intensivos, estadio de la sepsis, focalización, disfunción multiorgánica, tratamiento empleado, estado al egreso. Resultados: Ingresaron en estadio de sepsis severa y shock séptico 32 pacientes (43,9 %); fueron más afectados los menores de un año (62,5 %), menores de tres meses (37,5 %) y con enfermedad crónica subyacente (37,5 %). El 90.6 % fue referido del cuerpo de guardia. Predominó la focalización de la infección en el aparato respiratorio, digestivo y la infección no focalizada. La mayoría de los pacientes recibió fluidoterapia entre 20 y 40 ml/kg en la primera hora, el uso de antibióticos y drogas vasoactivas fue oportuno. El 75 % evolucionó a la disfunción multiorgánica y el 46,88 % falleció, este representó el 27,8 % de la mortalidad hospitalaria. Conclusiones: la mortalidad por sepsis severa y shock séptico es elevada, muere uno de cada 2,1 pacientes.

Background: severe sepsis and septic shock are one of the causes of morbidity and mortality in the pediatric population worldwide. There has been an increase in patients admitted with these stages of sepsis in recent years in the Pediatric Intensive Care Unit of Sancti Spíritus. Objective: to describe the clinical and epidemiological characteristics of severe sepsis and septic shock in the Pediatric Intensive Care Unit of Sancti Spíritus from 2005 to 2008. Methodology: a retrospective study of patients admitted to the Pediatric Intensive Care Unit of Sancti Spíritus with severe sepsis and septic shock in the studied period with the variables age, sex, risk factors for sepsis, place of reference to the Intensive Care Unit, stage of sepsis, targeting, multiple organ dysfunction, used treatment and discharge status. Results: 32 patients were admitted with severe sepsis stadium and septic shock (43.9 %); most affected were children under one year (62.5 %), less than 3 months (37.5 %) and underlying chronic illness (37.5 %). 90.6 % were referred from the emergency rooms. The focus of infection in the respiratory, gastrointestinal apparatus and unfocused infection prevailed. Most of the patients received fluid between 20 and 40 ml/kg in the first hour, the use of antibiotics and vasoactive drugs was appropriate. 75 % progressed to multiorgan dysfunction and 46.88 % died, this accounted for 27.8 % of hospital mortality. Conclusions: the mortality from severe sepsis and septic shock is high, die 1 for each 2.1 patients.