Long-Term Effects of a Stepwise, Multimodal, Non-Restrictive Antimicrobial Stewardship Programme for Reducing Broad-Spectrum Antibiotic Use in the ICU.

Information on the long-term effects of non-restrictive antimicrobial stewardship (AMS) strategies is scarce. We assessed the effect of a stepwise, multimodal, non-restrictive AMS programme on broad-spectrum antibiotic use in the intensive care unit (ICU) over an 8-year period. Components of the AMS were progressively implemented. Appropriateness of antibiotic prescribing was also assessed by monthly point-prevalence surveys from 2013 onwards. A Poisson regression model was fitted to evaluate trends in the reduction of antibiotic use and in the appropriateness of their prescription. From 2011 to 2019, a total of 12,466 patients were admitted to the ICU. Antibiotic use fell from 185.4 to 141.9 DDD per 100 PD [absolute difference, -43.5 (23%), 95% CI -100.73 to 13.73; p = 0.13] and broad-spectrum antibiotic fell from 41.2 to 36.5 [absolute difference, -4.7 (11%), 95% CI -19.58 to 10.18; p = 0.5]. Appropriateness of antibiotic prescribing rose by 11% per year [IRR: 0.89, 95% CI 0.80 to 1.00; p = 0.048], while broad-spectrum antibiotic use showed a dual trend, rising by 22% until 2015 and then falling by 10% per year since 2016 [IRR: 0.90, 95% CI 0.81 to 0.99; p = 0.03]. This stepwise, multimodal, non-restrictive AMS achieved a sustained reduction in broad-spectrum antibiotic use in the ICU and significantly improved appropriateness of antibiotic prescribing.

LipidMS 3.0: an R-package and a web-based tool for LC-MS/MS data processing and lipid annotation.

MOTIVATION: LipidMS was initially envisioned to use fragmentation rules and data-independent acquisition (DIA) for lipid annotation. However, data-dependent acquisition (DDA) remains the most widespread acquisition mode for untargeted LC-MS/MS-based lipidomics. Here, we present LipidMS 3.0, an R package that not only adds DDA and new lipid classes to its pipeline but also the required functionalities to cover the whole data analysis workflow from pre-processing (i.e. peak-peaking, alignment and grouping) to lipid annotation. RESULTS: We applied the new workflow in the data analysis of a commercial human serum pool spiked with 68 representative lipid standards acquired in full scan, DDA and DIA modes. When focusing on the detected lipid standard features and total identified lipids, LipidMS 3.0 data pre-processing performance is similar to XCMS, whereas it complements the annotations returned by MS-DIAL, providing a higher level of structural information and a lower number of incorrect annotations. To extend and facilitate LipidMS 3.0 usage among less experienced R-programming users, the workflow is also implemented as a web-based application. AVAILABILITY AND IMPLEMENTATION: The LipidMS R-package is freely available at https://CRAN.R-project.org/package=LipidMS and as a website at http://www.lipidms.com. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

The influence of postoperative albumin levels on the outcome of cardiac surgery.

BACKGROUND: The prognostic role of low postoperative serum albumin levels (SAL) after cardiac surgery (CS) remains unclear in patients with normal preoperative SAL. Our aim was to evaluate the influence of SAL on the outcome of CS. METHODS: Prospective observational study. Patients undergoing CS with normal preoperative SAL and nutritional status were included and classified into different subgroups based on SAL at 24 h after CS. We assessed outcomes (i.e., in-hospital mortality, postoperative complications and long-term survival) and results were analyzed among the different subgroups of SAL. RESULTS: We included 2818 patients. Mean age was 64.5 ± 11.6 years and body mass index 28.0 ± 4.3Kg·m- 2. 5.8%(n = 162) of the patients had normal SAL levels(≥35 g·L- 1), 32.8%(n = 924) low deficit (30-34.9 g·L- 1), 44.3%(n = 1249) moderate deficit (25-29.9 g·L- 1), and 17.1%(n = 483) severe deficit(< 25 g·L- 1). Higher SAL after CS was associated with reduced in-hospital (OR:0.84;95% CI:0.80-0.84; P = 0.007) and long-term mortality (HR:0.85;95% CI:0.82-0.87;P < 0.001). Subgroups of patients with lower SAL showed worst long-term survival (5-year mortality:94.3% normal subgroup, 87.4% low, 83.1% moderate and 72.4% severe;P < 0.001). Multivariable analysis showed higher in-hospital mortality, sepsis, hemorrhage related complications, and ICU stay in subgroups of patients with lower SAL. Predictors of moderate and severe hypoalbuminemia were preoperative chronic kidney disease, previous CS, and longer cardiopulmonary bypass time. CONCLUSIONS: The presence of postoperative hypoalbuminemia after CS is frequent and the degree of hypoalbuminemia may be associated with worst outcomes, even in the long-term scenario.

Outcomes of abdominal surgery in patients with liver cirrhosis.

Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.

Evaluation of Serial Arterial Lactate Levels as a Predictor of Hospital and Long-Term Mortality in Patients After Cardiac Surgery.

OBJECTIVES: Although hyperlactatemia is common after cardiac surgery, its value as a prognostic marker is unclear. The aim of the present study was to determine whether postoperative serial arterial lactate (AL) measurements after cardiac surgery could predict outcome. DESIGN: Prospective, observational study. SETTING: Surgical intensive care unit in a tertiary-level university hospital. PARTICIPANTS: Participants included 2,935 consecutive patients. INTERVENTIONS: AL was measured on admission to the intensive care unit and 6, 12, and 24 hours after surgery, and evaluated together with clinical data and outcomes including in-hospital and long-term mortality. MEASUREMENTS AND MAIN RESULTS: In-hospital and long-term mortality (mean follow-up 6.3±1.7 years) were 5.9% and 8.7%, respectively. Compared with survivors, nonsurvivors showed higher mean AL values in all measurements (p<0.001). Hyperlactatemia (AL>3.0 mmol/L) was a predictor for in-hospital mortality (odds ratio = 1.468; 95% confidence interval = 1.239-1.739; p<0.001) and long-term mortality (hazard ratio = 1.511; 95% confidence interval = 1.251-1.825; p<0.001). Recent myocardial infarction and longer cardiopulmonary bypass time were predictors of hyperlactatemia. The pattern of AL dynamics was similar in both groups, but nonsurvivors showed higher AL values, as confirmed by repeated measures analysis of variance (p<0.001). The area under the curve also showed higher levels of AL in nonsurvivors (80.9±68.2 v 49.71±25.8 mmol/L/h; p = 0.038). Patients with hyperlactatemia were divided according to their timing of peak AL, with higher mortality and worse survival in patients in whom AL peaked at 24 hours compared with other groups (79.1% v 86.7%-89.2%; p = 0.03). CONCLUSIONS: The dynamics of the postoperative AL curve in patients undergoing cardiac surgery suggests a similar mechanism of hyperlactatemia in survivors and nonsurvivors, albeit with a higher production or lower clearance of AL in nonsurvivors. The presence of a peak of hyperlactatemia at 24 hours is associated with higher in-hospital and long-term mortality.

Influence of cirrhosis in cardiac surgery outcomes.

Liver cirrhosis has evolved an important risk factor for cardiac surgery due to the higher morbidity and mortality that these patients may suffer compared with general cardiac surgery population. The presence of contributing factors for a poor outcome, such as coagulopathy, a poor nutritional status, an adaptive immune dysfunction, a degree of cirrhotic cardiomyopathy, and a degree of renal and pulmonary dysfunction, have to be taken into account for surgical evaluation when cardiac surgery is needed, together with the degree of liver disease and its primary complications. The associated pathophysiological characteristics that liver cirrhosis represents have a great influence in the development of complications during cardiac surgery and the postoperative course. Despite the population of cirrhotic patients who are referred for cardiac surgery is small and recommendations come from small series, since liver cirrhotic patients have increased their chance of survival in the last 20 years due to the advances in their medical care, which includes liver transplantation, they have been increasingly considered for cardiac surgery. Indeed, there is an expected rise of cirrhotic patients within the cardiac surgical population due to the increasing rates of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, especially in western countries. In consequence, a more specific approach is needed in the assessment of care of these patients if we want to improve their management. In this article, we review the pathophysiology and outcome prediction of cirrhotic patients who underwent cardiac surgery.

The influence of body mass index on outcomes in patients undergoing cardiac surgery: does the obesity paradox really exist?

PURPOSE: Obesity influences risk stratification in cardiac surgery in everyday practice. However, some studies have reported better outcomes in patients with a high body mass index (BMI): this is known as the obesity paradox. The aim of this study was to quantify the effect of diverse degrees of high BMI on clinical outcomes after cardiac surgery, and to assess the existence of an obesity paradox in our patients. METHODS: A total of 2,499 consecutive patients requiring all types of cardiac surgery with cardiopulmonary bypass between January 2004 and February 2009 were prospectively studied at our institution. Patients were divided into four groups based on BMI: normal weight (18.5-24.9 kg∙m-2; n = 523; 21.4%), overweight (25-29.9 kg∙m-2; n = 1150; 47%), obese (≥ 30-≤ 34.9 kg∙m-2; n = 624; 25.5%) and morbidly obese (≥ 35kg∙m-2; n = 152; 6.2%). Follow-up was performed in 2,379 patients during the first year. RESULTS: After adjusting for confounding factors, patients with higher BMI presented worse oxygenation and better nutritional status, reflected by lower PaO2/FiO2 at 24h and higher albumin levels 48 h after admission respectively. Obese patients showed a higher risk for Perioperative Myocardial Infarction (OR: 1.768; 95% CI: 1.035-3.022; p = 0.037) and septicaemia (OR: 1.489; 95% CI: 1.282-1.997; p = 0.005). In-hospital mortality was 4.8% (n = 118) and 1-year mortality was 10.1% (n = 252). No differences were found regarding in-hospital mortality between BMI groups. The overweight group showed better 1-year survival than normal weight patients (91.2% vs. 87.6%; Log Rank: p = 0.029. HR: 1.496; 95% CI: 1.062-2.108; p = 0.021). CONCLUSIONS: In our population, obesity increases Perioperative Myocardial Infarction and septicaemia after cardiac surgery, but does not influence in-hospital mortality. Although we found better 1-year survival in overweight patients, our results do not support any protective effect of obesity in patients undergoing cardiac surgery.

Evaluation of the PaO2/FiO2 ratio after cardiac surgery as a predictor of outcome during hospital stay.

BACKGROUND: The arterial partial pressure of O2 and the fraction of inspired oxygen (PaO2/FiO2) ratio is widely used in ICUs as an indicator of oxygenation status. Although cardiac surgery and ICU scores can predict mortality, during the first hours after cardiac surgery few instruments are available to assess outcome. The aim of this study was to evaluate the usefulness of PaO2/FIO2 ratio to predict mortality in patients immediately after cardiac surgery. METHODS: We prospectively studied 2725 consecutive cardiac surgery patients between 2004 and 2009. PaO2/FiO2 ratio was measured on admission and at 3 h, 6 h, 12 h and 24 h after ICU admission, together with clinical data and outcomes. RESULTS: All PaO2/FIO2 ratio measurements differed between survivors and non-survivors (p < 0.001). The PaO2/FIO2 at 3 h after ICU admission was the best predictor of mortality based on area under the curve (p < 0.001) and the optimum threshold estimation gave an optimal cut-off of 222 (95% Confidence interval (CI): 202-242), yielding three groups of patients: Group 1, with PaO2/FIO2 > 242; Group 2, with PaO2/FIO2 from 202 to 242; and Group 3, with PaO2/FIO2 < 202. Group 3 showed higher in-ICU mortality and ICU length of stay and Groups 2 and 3 also showed higher respiratory complication rates. The presence of a PaO2/FIO2 ratio < 202 at 3 h after admission was shown to be a predictor of in-ICU mortality (OR:1.364; 95% CI:1.212-1.625, p < 0.001) and of worse long-term survival (88.8% vs. 95.8%; Log rank p = 0.002. Adjusted Hazard ratio: 1.48; 95% CI:1.293-1.786; p = 0.004). CONCLUSIONS: A simple determination of PaO2/FIO2 at 3 h after ICU admission may be useful to identify patients at risk immediately after cardiac surgery.

Influence of acute kidney injury on short- and long-term outcomes in patients undergoing cardiac surgery: risk factors and prognostic value of a modified RIFLE classification.

INTRODUCTION: The development of acute kidney injury (AKI) is associated with poor outcome. The modified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification for AKI, which classifies patients with renal replacement therapy needs according to RIFLE failure class, improves the predictive value of AKI in patients undergoing cardiac surgery. Our aim was to assess risk factors for post-operative AKI and the impact of renal function on short- and long-term survival among all AKI subgroups using the modified RIFLE classification. METHODS: We prospectively studied 2,940 consecutive cardiosurgical patients between January 2004 and July 2009. AKI was defined according to the modified RIFLE system. Pre-operative, operative and post-operative variables usually measured on and during admission, which included main outcomes, were recorded together with cardiac surgery scores and ICU scores. These data were evaluated for association with AKI and staging in the different RIFLE groups by means of multivariable analyses. Survival was analyzed via Kaplan-Meier and a risk-adjusted Cox proportional hazards regression model. A complete follow-up (mean 6.9 ± 4.3 years) was performed in 2,840 patients up to April 2013. RESULTS: Of those patients studied, 14% (n = 409) were diagnosed with AKI. We identified one intra-operative (higher cardiopulmonary bypass time) and two post-operative (a longer need for vasoactive drugs and higher arterial lactate 24 hours after admission) predictors of AKI. The worst outcomes, including in-hospital mortality, were associated with the worst RIFLE class. Kaplan-Meier analysis showed survival of 74.9% in the RIFLE risk group, 42.9% in the RIFLE injury group and 22.3% in the RIFLE failure group (P <0.001). Classification at RIFLE injury (Hazard ratio (HR) = 2.347, 95% confidence interval (CI) 1.122 to 4.907, P = 0.023) and RIFLE failure (HR = 3.093, 95% CI 1.460 to 6.550, P = 0.003) were independent predictors for long-term patient mortality. CONCLUSIONS: AKI development after cardiac surgery is associated mainly with post-operative variables, which ultimately could lead to a worst RIFLE class. Staging at the RIFLE injury and RIFLE failure class is associated with higher short- and long-term mortality in our population.

Thrombocytopenia as a mortality risk factor in acute respiratory failure in H1N1 influenza.

BACKGROUND: A small proportion of patients with influenza H1N1 rapidly develop acute respiratory failure and are a problem for intensive care units (ICUs). Although certain clinical risk factors have been identified, few measurable biochemical/haematological markers able to predict poor outcome have been reported. The aims of the present report are to show which variables on and during admission are associated with increased in-hospital mortality in patients admitted to the ICU with acute respiratory failure due to H1N1 influenza. METHODS: A prospective observational study at two ICUs was carried out between August 2009 and March 2011. The study period covered two waves of pandemic influenza A H1N1 in Spain. Clinical and laboratory data on and during ICU admission were recorded for the purpose of analysis. RESULTS: Sixty patients with acute respiratory failure due to H1N1 influenza were admitted during the period described above; 63.3% (n = 38) were male and the mean age was 49.2 ± 14 years. Regarding comorbidities, 46.7% (n = 28) were smokers, 38% (n = 23) had hypertension, 30% (n = 18) had a body mass index (BMI) >30 kg/m2, 30% (n = 18) had chronic obstructive pulmonary disease and 26% (n = 16) had cardiac insufficiency; 16.6% (n = 10) had bacterial co-infection, 70% (n = 42) required invasive mechanical ventilation and 48.3% (n = 29) non-invasive mechanical ventilation. Mortality was 20% (n = 12). Comparing survivors with non-survivors, univariate analysis revealed significant differences in BMI, creatinine, haemoglobin, platelets, arterial pH, pCO2, and the rate of bacterial co-infection. In the multivariate analysis, only the presence of lower platelet count was statistically significant (214 ± 101 vs 113 ± 82 ×109/L; p = 0.009). Patients with thrombocytopenia showed a lower in-hospital survival rate (55%vs92.5%; Log Rank = 0.008). CONCLUSIONS: Thrombocytopenia could be valuable marker of in-hospital mortality in patients with respiratory failure due to H1N1 influenza in the ICU scenario.

Adaptación de puesto de trabajo en dos casos de narcolepsia / Workplace accomodations for two workers with narcolepsy

Describimos dos casos de trabajadores valorados en nuestro Servicio de Prevención, el primero trabajaba como pinche de cocina de un hospital y la segunda era médico de Atención Primaria, ambos estaban diagnosticados de narcolepsia y tenían reconocido distinto grado de minusvalía. Se evaluaron los riesgos de sus puestos de trabajo, se analizaron sus tareas, se les realizó un reconocimiento médico y se prescribieron unas recomendaciones adaptativas, incluyendo evitar la exposición a riesgo de accidentes y medidas para adecuar la higiene del sueño. La narcolepsia es una enfermedad poco frecuente pero con importantes repercusiones socio-laborales. Un mejor conocimiento de la enfermedad y la adaptación de puestos de trabajo pueden ayudar a mejorar la calidad de vida los trabajadores que la padecen(AU)

We describe the case of two workers evaluated in our occupational health unit. The first worker was a kitchen aide; the second was a primary care physician. Both had been diagnosed with narcolepsy and had obvious disability. We assessed occupational hazards related to their jobs, analysed their tasks, and performed medical examinations. Afterwards, we offered recommendations to the patients, consisting of avoidance of situations involving a risk of work accidents and improving their sleep habits. Narcolepsy is a rare disorder, but it has important social and occupational consequences. A better understanding of the disease and some work accommodations can help improve the quality of life of affected workers(AU)

[Workplace accomodations for two workers with narcolepsy]. / Adaptación de puesto de trabajo en dos casos de narcolepsia.

We describe the case of two workers evaluated in our occupational health unit. The first worker was a kitchen aide; the second was a primary care physician. Both had been diagnosed with narcolepsy and had obvious disability.We assessed occupational hazards related to their jobs, analysed their tasks, and performed medical examinations. Afterwards, we offered recommendations to the patients, consisting of avoidance of situations involving a risk of work accidents and improving their sleep habits. Narcolepsy is a rare disorder, but it has important social and occupational consequences. A better understanding of the disease and some work accommodations can help improve the quality of life of affected workers.

Short-term independent mortality risk factors in patients with cirrhosis undergoing cardiac surgery.

OBJECTIVES: Cirrhosis represents a serious risk in patients undergoing cardiac surgery. Several preoperative factors identify cirrhotic patients as high risk for cardiac surgery; however, a patient's preoperative status may be modified by surgical intervention and, as yet, no independent postoperative mortality risk factors have been identified in this setting. The objective of this study was to identify preoperative and postoperative mortality risk factors and the scores that are the best predictors of short-term risk. METHODS: Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Forty-two (72%) patients were operated on for valve replacement, 9 (16%) for a CABG and 7 (12%) for both (CABG and valve replacement). Thirty-four (58%) patients were classified as Child-Turcotte-Pugh class A, 21 (36%) as class B and 3 (5%) as class C. We evaluated the variables that are usually measured on admission and during the first 24 h of the postoperative period together with potential operative predictors of outcome, such as cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, model for end-stage liver disease, United Kingdom end-stage liver disease score) and ICU scores (acute physiology and chronic health evaluation II and III, simplified acute physiology score II and III, sequential organ failure assessment). RESULTS: Seven patients (12%) died in-hospital, of whom 5 were Child-Turcotte-Pugh class B and 2 class C. Comparing survivors vs non-survivors, univariate analysis revealed that variables associated with short-term outcome were international normalized ratio (1.5 ± 0.24 vs 2.2 ± 0.11, P < 0.0001), presurgery platelet count (171 ± 87 vs 113 ± 52 l nl(-1), P = 0.031), presurgery haemoglobin count (11.8 ± 1.8 vs 10.2 ± 1.4 g dl(-1), P = 0.021), total need for erythrocyte concentrates (2 ± 3.4 vs 8.5 ± 8 units, P < 0.0001), PaO(2)/FiO(2) at 12 h after ICU admission (327 ± 84 vs 257 ± 78, P = 0.04), initial central venous pressure (11 ± 3 vs 16 ± 4 mmHg, P = 0.02) and arterial blood lactate concentration 24 h after admission (1.8 ± 0.5 vs 2.5 ± 1.3 mmol l(-1), P = 0.019). Multivariate analysis identified initial central venous pressure as the only independent factor associated with short-term outcome (P = 0.027). The receiver operating characteristic curve showed that the model for end-stage Liver disease score had a better predictive value for short-term outcome than other scores (AUC: 90.5 ± 4.4%; sensitivity: 85.7%; specificity: 83.7%), although simplified acute physiology score III was acceptable. CONCLUSIONS: We conclude that central venous pressure could be a valuable predictor of short-term outcome in patients with cirrhosis undergoing cardiac surgery. The model for end-stage liver disease score is the best predictor of cirrhotic patients who are at high risk for cardiac surgery. Sequential organ failure assessment and simplified acute physiology score III are also valuable predictors.

Higher requirements of dialysis in severe lithium intoxication.

Severe lithium poisoning is a frequent condition in the intoxicated intensive care unit population. Dialysis is the treatment of choice, but no clinical markers predicting higher requirement for dialysis have been identified to date. We analyze the characteristics of lithium overdose patients needing dialysis to improve lithium clearance, and identify the ones associated with higher dialysis requirement. This is an observational, retrospective study of 14 patients with lithium poisoning admitted from 2004 to 2009. Median age was 41.8 ± 16.1 years. Poisonings were acute in 7.1%, acute-on-chronic in 64.28%, and chronic in 28.5% of cases. Comparing clinical and biochemical data in patients requiring more than one dialysis session with those requiring only one session, the univariate analysis showed differences at admission in creatinine clearance (40.5 ± 23 vs. 73.3 ± 24.9 mL/min, P = 0.025), white blood cells (17,528 ± 3,530 vs. 11,580 ± 3360 cells/L, P = 0.007), and blood sodium concentration (134.8 ± 5.9 vs. 141.8 ± 8.4 mmol/L, P=0.035). We measured the degree of association between the number of sessions and the variables with partial correlations. High lithium levels (P = 0.006, r = 0.69), low creatinine clearance (P = 0.04, r = -0.55), and low blood sodium concentration (P = 0.024, r = -0.59) were associated with a greater number of dialysis sessions. The correlation remained significant for blood sodium concentration (P = 0.016, r = -0.67) after adjustment for creatinine clearance and initial lithium levels. Presence on admission of low creatinine clearance, low blood sodium concentration, and/or high lithium levels correlated with a higher number of dialysis sessions in severe lithium poisoning. These factors, especially low blood sodium concentration, are associated with higher dialysis requirements in severe lithium intoxication.

Bacteremia related with arterial catheter in critically ill patients.

OBJECTIVE: Catheter-related bloodstream infections (CR-BSI) are an increasing problem in the management of critically ill patients. Our objective was to analyze the incidence and epidemiology of CR-BSI in arterial catheters (AC) in a population of critically ill patients. METHODS: We conducted a two-year, prospective, non-randomized study of patients admitted for > 24 h in a 24-bed medical-surgical major teaching ICU. We analyzed the arterial catheters and differentiated between femoral and radial locations. Difference testing between groups was performed using the two-tailed t-test and chi-square test as appropriate. Multivariate logistic regression analyses were conducted to identify independent predictors of CR-BSI occurrence and type of micro-organism responsible. RESULTS: The study included 1456 patients requiring AC placement for ≥ 24 h. A total of 1543 AC were inserted for 14,437 catheter days. The incidence of AC-related bloodstream infections (ACR-BSI) was 3.53 episodes per 1000 catheter days. In the same period the incidence of central venous catheter (CVC)-related bloodstream infections was 4.98 episodes per 1000 catheter days. Logistic regression analysis showed that days of insertion (OR: 1.118 95% confidence interval (CI) 1.026-1.219) and length of ICU stay (OR: 1.052 95% CI: 1.025-1.079) were associated with a higher risk of ACR-BSI. Comparing 705 arterial catheters in femoral location with 838 in radial location, no significant differences in infection rates were found, although there was a trend toward a higher rate among femoral catheters (4.13 vs. 3.36 episodes per 1000 catheter days) (p = 0.72). Among patients with ACR-BSI, Gram-negative bacteria were isolated in 16 episodes (61.5%) in the femoral location and seven (28%) in radial location (OR: 2.586; 95% CI: 1.051-6.363). CONCLUSIONS: We concluded that as has been reported for venous catheters ACR-BSI plays an important role in critically ill patients. Days of insertion and length of ICU stay increase the risk of ACR-BSI. The femoral site increases the risk for Gram-negative infection.

Impacto de un programa de prevención de la bacteriemia relacionada con el catéter en una unidad de cuidados intensivos de un hospital terciario / Impact of a prevention program for catheter-related bloodstream infection in the intensive care unit of a tertiary hospital

La bacteriemia relacionada con catéteres (BRC) vasculares aumenta la morbimortalidad de los pacientes ingresados en la unidad de cuidados intensivos (UCI). La estrategia óptima para la prevención de la BRC no está bien definida. La comparación de las tasas de BRC con las facilitadas por programas como el National Nosocomial Infection Surveillance System de los EE. UU. o el Estudio Nacional de Vigilancia de Infección Nosocomial (ENVIN) permiten determinar la necesidad de aplicar medidas de control. En el año 2000 se detectaron tasas de BRC en las UCI del Hospital Universitario de Bellvitge muy por encima de las publicadas por el ENVIN. Objetivo Evaluar el impacto que tiene sobre las tasas de BRC la aplicación de un protocolo para el uso adecuado de catéteres intravasculares en una UCI. Metodología Estudio prospectivo de pacientes ingresados en las UCI de un hospital terciario en el período de mayo a junio durante los años 2000 a 2004. En el año 2001 se aplicó un programa de prevención de la BRC que incluía aspectos relacionados con la inserción y el mantenimiento del catéter en los pacientes de la UCI. Se calcularon las tasas de infección por 1.000 días de catéter en los diferentes períodos bimensuales y se compararon los resultados del año 2000 con los del año 2004 mediante el análisis de la odds ratio (OR) y de su intervalo de confianza (IC) (..) (AU)

Introduction Catheter-related bloodstream infection (CR-BSI) is a cause of morbidity and mortality in intensive care units, and the optimal approach for preventing these infections is not well defined. Comparison of CR-BSI rates with those provided by programs such as the National Nosocomial Infection Surveillance System (NNISS) from the USA and the Spanish National Nosocomial Infection Surveillance Study (ENVIN), enable determination of the need to implement control measures. In 2000, we found that the CR-BSI rates in UCIs of our hospital were much higher than the data reported by ENVIN. Objective To assess the impact of implementing a protocol for proper use of intravascular catheters on CR-BSI rates in the intensive care unit (ICU) of a tertiary hospital. Methods Prospective study of patients admitted to the ICUs of a tertiary hospital in the months of May and June, from 2000 to 2004. In 2001, a CR-BSI prevention program including aspects related to catheter insertion and maintenance in ICU patients was implemented. We calculated infection rates per 1000 days of catheter use in all the 2-month periods studied, and compared the 2000 and 2004 results by analysis of the odds ratios and confidence intervals. Results A total of 923 patients were included. Mean age was 58.7 years (SD: 15.4), mean ICU stay was 11.6 days (SD: 11.4), mean SAPSII was 28.2 (SD: 15.9), and mortality was 20.5%. There was a significant reduction in CR-BSI rates from 13.3 episodes per 1000 days of catheter use in the first period to 3.21 in the last period (OR=3.53, 95% CI: 2.36–5.31).Conclusions Application of a prevention program for CR-BSI and a system for monitoring BSI rates led to a significant, sustained reduction in these infections (AU)

[Impact of a prevention program for catheter-related bloodstream infection in the intensive care unit of a tertiary hospital]. / Impacto de un programa de prevención de la bacteriemia relacionada con el catéter en una unidad de cuidados intensivos de un hospital terciario.

INTRODUCTION: Catheter-related bloodstream infection (CR-BSI) is a cause of morbidity and mortality in intensive care units, and the optimal approach for preventing these infections is not well defined. Comparison of CR-BSI rates with those provided by programs such as the National Nosocomial Infection Surveillance System (NNISS) from the USA and the Spanish National Nosocomial Infection Surveillance Study (ENVIN), enable determination of the need to implement control measures. In 2000, we found that the CR-BSI rates in UCIs of our hospital were much higher than the data reported by ENVIN. OBJECTIVE: To assess the impact of implementing a protocol for proper use of intravascular catheters on CR-BSI rates in the intensive care unit (ICU) of a tertiary hospital. METHODS: Prospective study of patients admitted to the ICUs of a tertiary hospital in the months of May and June, from 2000 to 2004. In 2001, a CR-BSI prevention program including aspects related to catheter insertion and maintenance in ICU patients was implemented. We calculated infection rates per 1000 days of catheter use in all the 2-month periods studied, and compared the 2000 and 2004 results by analysis of the odds ratios and confidence intervals. RESULTS: A total of 923 patients were included. Mean age was 58.7 years (SD: 15.4), mean ICU stay was 11.6 days (SD: 11.4), mean SAPSII was 28.2 (SD: 15.9), and mortality was 20.5%. There was a significant reduction in CR-BSI rates from 13.3 episodes per 1000 days of catheter use in the first period to 3.21 in the last period (OR=3.53, 95% CI: 2.36-5.31). CONCLUSIONS: Application of a prevention program for CR-BSI and a system for monitoring BSI rates led to a significant, sustained reduction in these infections.

Acidosis láctica y metformina. Tratamiento combinado con hemodiálisis y hemofiltración / Metformin-associated lactic acidosis. Combined treatment with haemodialysis and continuous hemofiltration

Presentamos un caso de acidosis láctica grave secundaria al consumo de metformina. Mujer de 61 años de edad con antecedentes de diabetes mellitus que prosiguió el tratamiento con metformina a pesar de estar en ayunas por intolerancia oral a alimentos y vómitos durante una semana. Presentó acidosis láctica grave (pH, 7,03; bicarbonato, 3,6 mEq/l; lactato, 18,58 mEq/l) e insuficiencia renal aguda (urea, 17,9 mmol/l; creatinina,634 mmol/l; Na+, 144 mmol/l; K+, 5,7 mmol/l), a pesar del tratamiento con hemodiálisis y bicarbonato intravenoso, y posteriormente requirió hemodiafiltración venovenosa continua, 2 sesiones de 8 h. Su curso evolutivo resultó satisfactorio. La asociación de metformina y acidosis láctica comporta un alto índice de mortalidad. Las técnicas de depuración extrarrenal continuas deberían considerarse como tratamiento precoz en los casos en que haya esta asociación (AU)

We report a case of severe lactic acidosis due to metformin ingestion in a 61-yearold woman with diabetes mellitus who continued taking metformin despite fastingfor a week due to food intolerance and vomiting. The patient showed severe lactic acidosis (arterial pH 7.03, bicarbonate 3.6 mEq/l, lactate 18.58 mEq/l) and acuterenal failure (urea 17.9 mmol/l, creatinine 634 mol/l, Na+ 144 mmol/l, K+ 5.7 mmol/l). Despite hemodialysis and intravenous bicarbonate therapy, the patient required continuous hemodiafiltration for 16 hours. Outcome was favorable. Metformininduced lactic acidosis is associated with a high mortality rate. Early renal replacement therapy should be considered as the main emergency treatment in these cases (AU)

Intoxicación grave por digoxina. Utilización exitosa del tratamiento clásico / Severe Digoxin Intoxication. Successful Use of the Classic Treatment

En nuestro medio, el tratamiento de la intoxicación digitálica con anticuerpos Fab es frecuentemente difícil a causa de la baja disponibilidad de este fármaco en la mayoría de centros. Presentamos una paciente que ingresó en nuestro hospital tras una ingesta masiva de digoxina y que fue tratada de forma exitosa con tratamiento convencional. Se discute posteriormente la necesidad de individualizar la opción terapéutica en este tipo de intoxicaciones con el objeto de reducir, en lo posible, el gasto sanitario. (AU)