The effect of age on clinical outcomes in critically ill brain-injured patients.

PURPOSE: We studied the impact of age on survival and functional recovery in brain-injured patients. METHODS: We performed an observational cohort study of all consecutive adult patients with brain injury admitted to ICU in 8 years. To estimate the optimal cut-off point of the age associated with unfavorable outcomes (mRS 3-6), receiver operating characteristic (ROC) curve analyses were used. Multivariate logistic regression analyses were performed to identify prognostic factors for unfavorable outcomes. RESULTS: We included 619 brain-injured patients. We identified 60 years as the cut-off point at which the probability of unfavorable outcomes increases. Patients ≥ 60 years had higher severity scores at ICU admission, longer duration of mechanical ventilation, longer ICU and hospital stays, and higher mortality. Factors identified as associated with unfavorable outcomes (mRS 3-6) were an advanced age (≥ 60 years) [Odds ratio (OR) 4.59, 95% confidence interval (CI) 2.73-7.74, p < 0.001], a low GCS score (≤ 8 points) [OR 3.72, 95% CI 1.95-7.08, p < 0.001], the development of intracranial hypertension [OR 5.52, 95% CI 2.70-11.28, p < 0.001], and intracerebral hemorrhage as the cause of neurologic disease [OR 3.87, 95% CI 2.34-6.42, p < 0.001]. CONCLUSION: Mortality and unfavorable functional outcomes in critically ill brain-injured patients were associated with older age (≥ 60 years), higher clinical severity (determined by a lower GCS score at admission and the development of intracranial hypertension), and an intracerebral hemorrhage as the cause of neurologic disease.

Factores de riesgo de reingreso en UCI y análisis de la mortalidad intrahospitalaria / Risk factors for readmission to ICU and analysis of intra-hospital mortality

IntroducciónLos pacientes críticos, a pesar de la recuperación inicial en la unidad de cuidados intensivos (UCI), pueden precisar reingreso en UCI o incluso fallecer en el mismo episodio hospitalario. Los objetivos son: conocer la incidencia e identificar factores de riesgo de reingreso en UCI, y determinar la mortalidad hospitalaria.MétodosEstudio de cohortes observacional de todos los pacientes ingresados consecutivamente más de 24h en la UCI del Hospital Universitario de Getafe entre el 1-04-2018 y el 30-09-2018 y dados de alta vivos de su primer ingreso en UCI.ResultadosDe los 164 pacientes vivos al alta de UCI, 14 (8,5%) fueron reingresados en UCI (2,4% en≤48h). El riesgo ajustado de reingreso en UCI fue mayor en los pacientes con déficit neurológico discapacitante previo al ingreso en UCI (odds ratio [OR]: 7,96; intervalo de confianza del 95% [IC 95%]: 1,55-40,92) o que recibieron fármacos vasoactivos (OR: 5,07; IC 95%: 1,41-18,29) durante su estancia en UCI. Los pacientes reingresados tuvieron mayor mortalidad hospitalaria (4 de 14 [29%] versus 5 de 150 [3%], p<0,001) y mayor estancia hospitalaria (74,5 [37,5-99,75] días versus 16 [9-34] días, mediana [rango intercuartílico], p=0,001).ConclusionesLos pacientes con déficit neurológico discapacitante previo al ingreso hospitalario o que recibieron fármacos vasoactivos durante la estancia en UCI tienen mayor riesgo de reingreso en UCI, lo que aumenta la estancia y la mortalidad hospitalaria.

Risk factors for readmission to ICU and analysis of intra-hospital mortality. / Factores de riesgo de reingreso en UCI y análisis de la mortalidad intrahospitalaria.

INTRODUCTION: Critical patients, despite initial recovery in the intensive care unit (ICU), may require readmission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality. METHODS: Observational cohort study of all patients admitted consecutively for more than 24hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission. RESULTS: Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at≤48hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mortality (4 of 14 [29%] versus 5 of 150 [3%], P<.001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P=.001). CONCLUSIONS: Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality.

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

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

Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study.

PURPOSE: Despite the evidence, the use of selective decontamination of the digestive tract (SDD) remains controversial, largely because of concerns that it may promote the emergence of antibiotic-resistant strains. The purpose of this study was to evaluate the long-term incidence of carriage of antibiotic-resistant bacteria (ARB), its clinical impact on developing infections and to explore risk factors of acquiring resistance. METHODS: This study was conducted in one 18-bed medical-surgical intensive care unit (ICU). All consecutive patients admitted to the ICU who were expected to require tracheal intubation for longer than 48 h were given a 4-day course of intravenous cefotaxime, and enteral polymyxin E, tobramycin, amphotericin B in an oropharyngeal paste and digestive solution. Oropharyngeal and rectal swabs were obtained on admission and once a week. Diagnostic samples were obtained on clinical indication. RESULTS: During 5 years 1,588 patients were included in the study. The incidence density of ARB was stable: 18.91 carriers per 1,000 patient-days. The incidence of resistant Enterobacteriaceae was stable; the resistance of Pseudomonas aeruginosa to tobramycin, amikacin and ciprofloxacin was strongly reduced; there was an increase of P. aeruginosa resistant to ceftazidime and imipenem, associated with the increase in imipenem consumption; the incidence of other nonfermenter bacilli and oxacillin-resistant Staphylococcus aureus was close to zero. Ninety-seven patients developed 101 infections caused by ARB: 23 pneumonias, 20 bloodstream infections and 58 urinary tract infections. Abdominal surgery was the only risk factor associated with ARB acquisition [risk ratio 1.56 (1.10-2.19)]. CONCLUSIONS: Long-term use of SDD is not associated with an increase in acquisition of resistant flora.