Etilefrina vs fenilefrina en hipotensión por anestesia espinal para cesárea: ensayo clínico multicéntrico, controlado, aleatorizado y doble ciego / Etilefrine vs. phenylephrine for hypotension during spinal anesthesia for cesarean section: Multicenter, randomized, double blind controlled clinical trial

Introduction: Hypotension after spinal anesthesia in cesarean section should be minimized. The use of vasopressors is an effective measure to treat hypotension. The objective of this paper is to compare the safety and effectiveness of etilefrine vs. phenylephrine in the management of this condition. Methods: This multicenter, double-blind trial between August 2009 and November 2010 included 196 patients with hypotension during spinal anesthesia for cesarean delivery; the patients were randomized to receive etilefrine or phenylephrine as vasopressor. The primary outcome was the fetal umbilical arterial pH. The secondary outcomes were: fetal acidosis (umbilical arterial pH < 7.20), Apgar score at 1 and 5 min, need for intubation and admission to the neonatal intensive care unit for newborns, and time of hypotension, total dose of vasopressor, atropine requirement, intravenous fluids volume and incidence of nausea and vomiting in mothers. Results: 98 patients received etilefrine and 98 phenylephrine. There were no differences in umbilical arterial pH (7.27 vs. 7.28, respectively, P = 0.493). The total dose of vasopressor (5.66 vs. 6.51ml, respectively, P = 0.024) and total time of hypotension (2.78 vs. 3.25 min, respectively, P = 0.021) were lower in the etilefrine group. Other outcomes studied showed no statistically significant differences. Conclusion: Etilefrine and phenylephrine are equally effective for the treatment of hypotension during spinal anesthesia for cesarean delivery. This study found no difference in the maternal or fetal outcomes.

Introducción: La hipotensión que ocurre luego de anestesia espinal para cesárea debe minimizarse. El uso de vasopresores es una medida eficaz para su tratamiento. El objetivo de este trabajo es comparar la seguridad y efectividad de etilefrina vs fenilefrina para manejo de esta condición. Métodos: En este estudio multicéntrico y doble ciego, entre agosto de 2009 y noviembre de 2010, 196 pacientes con hipotensión durante anestesia espinal para cesárea, fueron asignadas aleatoriamente para recibir etilefrina o fenilefrina como vasopresor. El resultado primario fue el pH arterial umbilical fetal. Los resultados secundarios fueron: acidosis fetal (pH arterial umbilical < 7,20), puntaje Apgar al 1 y 5 minutos, necesidad de intubación e ingreso a la unidad de cuidados intensivos neonatal para los recién nacidos; y tiempo de hipotensión, dosis total de vasopresor, necesidad de uso de atropina, líquidos endovenosos totales e incidencia de nausea y vómito para las madres. Resultados: 98 pacientes recibieron etilefrina y 98 fenilefrina. No se encontraron diferencias en el pH arterial umbilical (7,27 vs 7,28 respectivamente; p = 0,493). La dosis total de vasopresor (5,66 vs. 6,6 ml, respectivamente; P = 0,024) y el tiempo total de hipotensión (2,78 vs. 3,25 min, respectivamente; p = 0,021), fueron menores en el grupo de etilefrina. Los demás desenlaces estudiados no presentaron diferencia estadísticamente significativa. Conclusión: La etilefrina y la fenilefrina son igualmente efectivas para el tratamiento de la hipotensión por anestesia espinal para cesárea. Este estudio no encontró diferencia en los resultados fetales ni maternos.

Infecciones asociadas a dispositivos en unidades de cuidado intensivo académicas vs no académicas. ¿Hay diferencia? / Device-associated nosocomial infections in academics vs nonacademics intensive care units. Is there a difference?

Introducción: las infecciones nosocomiales asociadas a dispositivos aumentan la morbilidad y mortalidad en las unidades de cuidado intensivo. Objetivo: evaluar si el carácter docente de una unidad de cuidado intensivo incrementa la incidencia de infecciones nosocomiales. Métodos: estudio de una cohorte prospectiva de pacientes de la base de datos del Grupo de Vigilancia Epidemiológica de las UCI de Colombia desde noviembre de 2007 hasta diciembre del 2009. Se evalúo la asociación del carácter docente y la presencia de cualquier infección nosocomial asociada a dispositivos por medio de análisis bivariado y mutivariado. Resultados: fueron estudiados 31 863 pacientes en varias ciudades. Se encontró una incidencia de infecciones nosocomiales asociadas a dispositivos de 5,2 %, siendo la más común la neumonía asociada al ventilador. El análisis bivariado encontró como factores de riesgo el carácter docente, puntaje del APACHE II, ingreso por trauma, intoxicación o enfermedad pulmonar, unidad de cuidado intensivo quirúrgica y se encontró diferencia entre las ciudades. Las variables que mostraron asociación con la presencia de infecciones nosocomiales asociadas a dispositivos en el análisis multivariado fueron: estar hospitalizado en la ciudad 1, 2, 4 ó 5, diagnóstico de ingreso de trauma y cirugía; pero no se encontró asociación con la característica docente de la unidad de cuidado intensivo. Conclusión: el carácter docente no se asocia con un aumento de la incidencia de infecciones nosocomiales asociadas a dispositivos en las unidades de cuidado intensivo.

Device-Associated Nosocomial Infections (DANI) increase morbidity and mortality in intensive care units (ICU). The presence of students can theoretically increase the risk of such infections. Objective: The objective of this trial was to assess whether or not being a teaching hospital increases the incidence of DANI at ICU. Method: Prospective cohort study from the GRUVECO (Colombian National Group of Infection Surveillance) database since November 2007 to December 2009. We evaluated the association of academic nature and the presence of any DANI through bivariate and multivariate analysis. Results: A total of 31.863 patients were studied. The incidence of DANI was 5.2%, mainly ventilator-associated pneumonia Bivariated analysis demonstrated that risk factors for DANI were: academic ICUs, APACHE II score, admission for trauma, poisoning or lung disease and surgical ICUs; differences among geographic locations were also noticed. Variables associated with DANI in the multivariated analysis were: city 1, city 2, city 7 or city 4 and diagnosis of trauma or surgery, but no association was found with academic nature of ICU. Conclusions: Academic ICUs were not associated with increased incidence of DANI.

Renal injury study in critical ill patients in accordance with the new definition given by the Acute Kidney Injury Network.

OBJECTIVE: This research aims to apply the definition proposed by the Acute Kidney Injury Network (AKIN) research group to assess the incidence, risk factors, and outcomes in acute kidney injury (AKI) patients admitted at the intensive care unit (ICU). DESIGN: This is a retrospective cohort study. Patients who were admitted to the ICU from January 1, 2003 to December 31, 2004 were studied. INTERVENTIONS: Medical records of all patients were reviewed. Demographic information, diagnoses, risk factors for AKI, laboratory data, urinary output, frequency and days of exposure to mechanical ventilation, ICU and hospital stay, and outcomes were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 794 patients were studied. There were 39.8% of patients who presented AKI (stage 1: 13.9%, stage 2: 12%, stage 3: 13.9%). The variables that were associated with the presence of AKI in the multivariable analysis were as follows: sepsis (odds ratio [OR], 5.29; 95% confidence interval [CI], 3.36-8.33), heart failure (OR, 3.01; 95% CI, 1.59-5.67), vasopressor use (OR, 1.89; 95% CI, 1.26-2.83), and age (ß = 1.02; 95% CI, 1.01-1.03). The mean hospital stay increased with renal commitment: patients without AKI, 10.9 days; AKIN stage 1, 17.8; AKIN stage 2, 21.1; and AKIN stage 3, 22.1 days (P < .0001). Mortality rate increased as more advanced the AKI stage was (no AKI, 7.3%; AKI 1, 16.4%; AKI 2, 34.7%; and AKIN 3, 45.5%; P < .0001). CONCLUSIONS: All of the result indicators--stay days in ICU, hospital stay days, frequency and days of mechanical ventilation, and mortality--considerably increased with more acute AKI stage. The most important risk factor of AKI was the sepsis.