Análisis retrospectivo sobre la extubación en pacientes con patología neurológica aguda / Retrospective analysis on the extubation in patients with acute neurological pathology

Objetivo: Evaluar la idoneidad de la prueba de respiración espontánea para predecir el fracaso de la extubación de pacientes neurológicos y determinar los factores predictivos de fracaso. Diseño: Casos y controles. De enero de 2001 a diciembre de 2010. Ámbito: Unidad de Cuidados Intensivos. Pacientes: Enfermos neurológicos agudos sometidos a ventilación mecánica y posterior extubación. Se excluyeron: pacientes con cirugías neurológicas programadas, con patología neuromuscular, lesión medular, traqueotomía, politraumatismos con predominio de afectación del resto de los sistemas sobre el neurológico, aquellos que murieron en la Unidad de Cuidados Intensivos o que fueron trasladados. Variables de interés: Tasa de fracaso, infección intrahospitalaria, necesidad de traqueotomía, duración de la ventilación mecánica, estancia en la Unidad de Cuidados Intensivos y en el hospital, mortalidad en esta Unidad, en el hospital y a los 90 días, y factores asociados al fracaso. Resultados: De 479 pacientes, 208 fueron sometidos a prueba de respiración espontánea y posterior extubación. Cincuenta y cuatro (26%) fracasaron, la tasa de complicaciones, la estancia, la duración de la ventilación mecánica y la mortalidad fueron mayores que en el grupo de éxito. Los pacientes con accidente cerebrovascular [OR 4,256 (IC95% 1,442-12,561), p = 0,009] y necesidad de aspiraciones frecuentes [OR 5,699 (IC95% 1,863-17,432), p = 0,002] son más propensos al fracaso [ROC 0,73 (IC95% 0,628-0,840)]. Conclusiones: Los pacientes neurológicos presentan una elevada tasa de fracaso de la extubación con numerosas complicaciones asociadas y muerte. La prueba de respiración espontánea no predijo el éxito de la extubación. Los pacientes con accidente cerebrovascular y necesidad de aspiraciones frecuentes de secreciones se verían abocados a un mayor fracaso de extubación.(AU)

Objective: To assess the adequacy of the spontaneous breathing test to predict extubation failure in neurological patients undergoing mechanical ventilation and to determine factors associated with extubation failure. Design: Case-control study. Between January 2001 and December 2010. Setting: Intensive Care Unit. Patients: Acute neurological patients who underwent mechanical ventilation and were subsequently extubated. Patients with scheduled neurosurgery intervention, neuromuscular disease, spinal cord injury, tracheotomy, multiple trauma with less neurological damage than in other systems, those who died in the Intensive Care Unit or in hospital or those transferred to other hospital, were excluded. Variables of interest: Extubation failure rate, nosocomial infection, need for tracheostomy, duration of mechanical ventilation, ICU and hospital stay, mortality in the ICU or hospital, and at day 90, as well as failure-related factors. Results: Two-hundred and eight patients underwent spontaneous breathing trial, and were subsequently extubated. Fifty-four (26%) patients failed. Patients who failed extubation had a higher complication rate, received mechanical ventilation for more days, their hospitalization was longer, and the mortality rate was higher than in the success group. Patients with stroke [OR 4.256 (95%CI, 1.442-12.561), p=0.009] and those who required a greater number of aspirations during weaning [OR 5.699 (95%CI, 1.863-17.432), p=0.002] were susceptible to extubation failure [ROC curve 0.73 (0.628-0.840)]. Conclusion: Extubation failure in neurological patients is common and frequently associated with severe complications. The spontaneous breathing trial does not predict a successful extubation. Patients with stroke and those who need frequent aspiration of secretions would be doomed to further failure of extubation(AU)

[Bias in time delay in ICU admission as a mortality risk factor or "lead time bias"]. / Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias.

OBJECTIVE: To assess if delay in admission to the Intensive Care Unit (ICU), measured according to the prognostic estimation of survival in critical patients (EPEC) system, influences the final outcome of patients admitted to our ICU. DESIGN: Retrospective and systematic analysis of data collected during six months in 2003. SETTING: Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital. PATIENTS: Four hundred and eighty one patients consecutively admitted to our ICU and followedup to hospital discharge. MAIN INTEREST VARIABLES: Risk of death was estimated with the EPEC, SAPS II and MPM II 0. Variables collected were gender, age, origin of admission, risk of death by means of the 3 methods mentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead). RESULTS: A total of 44 out of 481 patients died during the hospital stay, overall admission delay being 0.7 +/- 1.98 hours (2.96 +/- 3.28, range 0.25-20 hours, for those with delay > 0). No differences were found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0). CONCLUSIONS: Our study does not make it possible to relate lead time bias with patient survival. Due to the EPEC design, it is possible to differentiate "physiopathological delay" (inappropriate detection of the critical situation) and "logistic delay" (conditioned by factors such as lack of available beds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias.

Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias / Bias in time delay in ICU admission as a mortality risk factor or “lead time bias”

Objetivo. Comprobar cómo el tiempo de retraso en el ingreso, cuantificado conforme al sistema EPEC, influye en el resultado final de los pacientes ingresados en nuestro Servicio de Medicina Intensiva.Diseño. Análisis retrospectivo de datos recogidosde forma sistemática y prospectiva durante un período de 6 meses del año 2003.Ámbito. Servicio de Medicina Intensiva de 19 camas (15 de la Unidad de Cuidados Intensivos convencional y 4 de Cuidados Intermedios) en un hospital docente de referencia.Pacientes. Cuatrocientos ochenta y un pacientesingresados en nuestro Servicio y seguidos hasta su alta hospitalaria. Principales variables de interés. El riesgo de muerte de los pacientes fue estimado por mediode EPEC, SAPS 2 y MPM II 0. Las variables recogidasfueron sexo, edad, procedencia, tipo de paciente,riesgo de muerte por los tres sistemas mencionados, retraso en el ingreso en horas (conforme EPEC) y estado vital (vivo o muerto) tanto a la salida de la Unidad de Cuidados Intensivos como al abandonar el hospital.Resultados. Fallecieron 44 pacientes de los 481ingresados, siendo el retraso global en el ingresode 0,7 ± 1,98 horas (2,96 ± 3,28, límites 0,25-20 horas,para aquellos con retraso > 0). No se enconencontrarondiferencias en el retraso de ingreso entre vivosy fallecidos, y existió una correlación muy malaentre el pronóstico realizado con consideracióndel tiempo de retraso en el ingreso y el que se estableció sin considerarlo (SAPS 2 y MPM II 0).Conclusiones. Nuestro estudio no permite relacionarel sesgo temporal (retraso en el ingreso)con la supervivencia o no de los pacientes. Por eldiseño de EPEC se distingue entre el «retraso fisiopatológico » (detección inapropiada de la situaciónde gravedad) y el «retraso logístico» (condicionadopor factores tales como falta de camas disponibles). Nuestro estudio y EPEC sólo consideran este último. No puede descartarse que el incremento de mortalidad respecto al pronóstico esté relacionado directamente con el primer tipo de retraso y no con el sesgo temporal globalmente considerado

Objective. To assess if delay in admission to theIntensive Care Unit (ICU), measured according tothe prognostic estimation of survival in critical patients (EPEC) system, influences the final outcomeof patients admitted to our ICU.Design. Retrospective and systematic analysis of data collected during six months in 2003. Setting. Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital.Patients. Four hundred and eighty one patientsconsecutively admitted to our ICU and followedup to hospital discharge Main interest variables. Risk of death was estimated with the EPEC, SAPS II and MPM II 0.Variables collected were gender, age, origin ofadmission, risk of death by means of the 3 methodsmentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead).Results. A total of 44 out of 481 patients diedduring the hospital stay, overall admission delaybeing 0.7 ± 1.98 hours (2.96 ± 3.28, range 0.25-20hours, for those with delay > 0). No differenceswere found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0).Conclusions. Our study does not make it possibleto relate lead time bias with patient survival.Due to the EPEC design, it is possible to differentiate“physiopathological delay” (inappropriate detection of the critical situation) and “logistic delay”(conditioned by factors such as lack of availablebeds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias

[Percutaneous tracheostomy in ventilated patients]. / Traqueostomía percutánea en pacientes ventilados.

INTRODUCTION: Percutaneous tracheostomy is an alternative to conventional surgical tracheostomy. It is associated to a more feasible procedure, that is less invasive and linked to a lower degree of complications. Herein, we review our experience since the implementation of this technique in our Department. DESIGN: Retrospective observational. SETTING: Nineteen-bed intensive care department, in a general reference teaching hospital. PATIENTS AND METHOD: A total of 115 of 130 tracheostomies performed from 2001 to 2003 were retrospectively analyzed. Collected data include epidemiological information, reason for performing the procedure, maintenance time of artificial airway before the tracheostomy and type of ventilatory support or oxygen supplementation before and after the procedure. The modified PEEP (PEEP-mod = FiO2 x PEEP) was calculated, sedation level received before and 4-6 hours after the technique and also 24 hours later, were reviewed. Subsequent patient evolution was collected. INTERVENTIONS: Observational study on the results of routine procedures. VARIABLES OF INTEREST: Blood gases indicators of effectiveness in oxygen supply and the need of mechanical ventilation support. RESULTS: Median age of the 115 reviewed patients was 65 years. The most common admission reasons were: brain vascular accident in 25 cases, head and neck injury in 21, cancer in 11 and sepsis in 10 patients. Tracheostomy was indicated because prolonged mechanical ventilation in 52 patients, coma in 28 and emergency or scheduled surgery in 10 cases. Median length of stay in the ICU before tracheostomy was 14 days. Ninety-two patients were discharged from the ICU, and 52 from the Hospital. The remaining patients died during their hospital stay. Serious complications appeared in 5 patients (4%); 3 of them were the development of fistulae and all of them occurred in patients in whom the tracheostomy was performed in the ICU at bedside. Before the procedure, 72 patients were under mechanical ventilation, but only 56 received ventilatory support 24 hours after tracheostomy. When PEEP-mod values were analyzed, first monitoring of median value was 1.6 (range 0 to 2), 4-6 hours time median value was 2 (1.4-2.45), and 24 hours later median value was 1.2 (0-2) (global variation, p < 0.001). CONCLUSIONS: In our experience, percutaneous tracheostomy performed at bedside in the ICU is an adequate solution with a low complication rate and its makes it possible to reduce the level of ventilatory support.

Traqueostomía percutánea en pacientes ventilados / Percutaneous tracheostomy in ventilated patients

Introducción. La traqueostomía percutánea es una alternativa a la traqueostomía quirúrgica convencional, asociada a una realización más ágil, menos invasora y con menor tasa de complicaciones. Revisamos los resultados obtenidos mediante esta técnica desde su implantación en nuestro Servicio. Diseño. Observacional, retrospectivo. Ámbito. Servicio de Medicina Intensiva de un Hospital docente de referencia, dotado de 19 camas. Pacientes y método. Se analizan 115 registros sobre 130 traqueostomías realizadas desde 2001 hasta 2003. Se recogen datos de filiación y epidemiológicos de los pacientes, motivo de realización de la técnica, tiempo de mantenimiento de la vía aérea antes de la traqueostomía y situación de soporte ventilatorio o de oxigenoterapia antes y después del procedimiento. Se calcula la presión positiva al final de la espiración modificada (PEEP-mod) (PEEP-mod = fracción inspirada de oxígeno [FiO2] x PEEP) y se revisa la sedación que recibían los pacientes antes de la traqueostomía, a las 4-6 horas de la misma y transcurridas 24 horas. Igualmente se recoge su evolución posterior. Intervenciones. Estudio observacional de resultados de pauta de actuación rutinaria. Variables de interés. Variables de efectividad de intercambio gaseoso en relación a la FiO2 administrada y la necesidad de soporte ventilatorio mecánico. Resultados. En los 115 pacientes revisados la mediana de edad fue de 65 años. Los diagnósticos de ingreso más comunes fueron: accidente vascular cerebral en 25 pacientes, traumatismos craneoencefálicos y cervicales en 21, neoplasias en 11 y sepsis en 10. Los principales para indicar la traqueostomía fueron: ventilación mecánica prolongada en 52 pacientes, coma en 28 y cirugía en 10. La mediana de estancia en el servicio de Medicina Intensiva antes de realizarse la traqueostomía fue de 14 días. Recibieron el alta del servicio de Medicina Intensiva 92 pacientes y el alta hospitalaria 52 pacientes; el resto falleció. Se produjeron complicaciones graves en 5 pacientes (4%); 3 de ellas consistieron en el desarrollo de fístulas, que ocurren en pacientes a los que se les realiza la traqueostomía en el servicio de Medicina Intensiva. Antes de la traqueostomía 72 pacientes recibían ventilación mecánica, y tras las primeras 24 horas postraqueostomía sólo 56 pacientes recibían soporte ventilatorio. Al analizar los valores de la PEEP-mod, la mediana del primer control es de 1,6 (rango 0 a 2), a las 4-6 horas la mediana es de 2 (1,4-2,45), y a las 24 horas la mediana es de 1,2 (0-2) (variación global, p < 0,001). Conclusiones. En nuestra experiencia la traqueostomía percutánea realizada intra-Unidad de Cuidados Intensivos (UCI) constituye una solución adecuada con una tasa baja de complicaciones y que permite disminuir la intensidad del soporte ventilatorio

Introduction. Percutaneous tracheostomy is an alternative to conventional surgical tracheostomy. It is associated to a more feasible procedure, that is less invasive and linked to a lower degree of complications. Herein, we review our experience since the implementation of this technique in our Department. Design. Retrospective observational. Setting. Nineteen-bed intensive care department, in a general reference teaching hospital. Patients and method. A total of 115 of 130 tracheostomies performed from 2001 to 2003 were retrospectively analyzed. Collected data include epidemiological information, reason for performing the procedure, maintenance time of artificial airway before the tracheostomy and type of ventilatory support or oxygen supplementation before and after the procedure. The modified PEEP (PEEP-mod = FiO2 x PEEP) was calculated, sedation level received before and 4-6 hours after the technique and also 24 hours later, were reviewed. Subsequent patient evolution was collected. Interventions. Observational study on the results of routine procedures. Variables of interest. Blood gases indicators of effectiveness in oxygen supply and the need of mechanical ventilation support. Results. Median age of the 115 reviewed patients was 65 years. The most common admission reasons were: brain vascular accident in 25 cases, head and neck injury in 21, cancer in 11 and sepsis in 10 patients. Tracheostomy was indicated because prolonged mechanical ventilation in 52 patients, coma in 28 and emergency or scheduled surgery in 10 cases. Median length of stay in the ICU before tracheostomy was 14 days. Ninety-two patients were discharged from the ICU, and 52 from the Hospital. The remaining patients died during their hospital stay. Serious complications appeared in 5 patients (4%); 3 of them were the development of fistulae and all of them occurred in patients in whom the tracheostomy was performed in the ICU at bedside. Before the procedure, 72 patients were under mechanical ventilation, but only 56 received ventilatory support 24 hours after tracheostomy. When PEEP-mod values were analyzed, first monitoring of median value was 1.6 (range 0 to 2), 4-6 hours time median value was 2 (1.4-2.45), and 24 hours later median value was 1.2 (0-2) (global variation, p < 0.001). Conclusions. In our experience, percutaneous tracheostomy performed at bedside in the ICU is an adequate solution with a low complication rate and its makes it possible to reduce the level of ventilatory support