Optimal Prone Position Duration in Patients With ARDS Due to COVID-19: The Omelette Pilot Trial.

BACKGROUND: Prone position (PP) has been widely used in the COVID-19 pandemic for ARDS management. However, the optimal length of a PP session is still controversial. This study aimed to evaluate the effects of prolonged versus standard PP duration in subjects with ARDS due to COVID-19. METHODS: This was a single-center, randomized controlled, parallel, and open pilot trial including adult subjects diagnosed with severe ARDS due to COVID-19 receiving invasive mechanical ventilation that met criteria for PP between March-September 2021. Subjects were randomized to the intervention group of prolonged PP (48 h) versus the standard of care PP (∼16 h). The primary outcome variable for the trial was ventilator-free days (VFDs) to day 28. RESULTS: We enrolled 60 subjects. VFDs were not significantly different in the standard PP group (18 [interquartile range [IQR] 0-23] VFDs vs 7.5 [IQR 0-19.0] VFDs; difference, -10.5 (95% CI -3.5 to 19.0, P = .08). Prolonged PP was associated with longer time to successful extubation in survivors (13.00 [IQR 8.75-26.00] d vs 8.00 [IQR 5.00-10.25] d; difference, 5 [95% CI 0-15], P = .001). Prolonged PP was also significantly associated with longer ICU stay (18.5 [IQR 11.8-25.3] d vs 11.50 [IQR 7.75-25.00] d, P = .050) and extended administration of neuromuscular blockers (12.50 [IQR 5.75-20.00] d vs 5.0 [IQR 2.0-14.5] d, P = .005). Prolonged PP was associated with significant muscular impairment according to lower Medical Research Council values (59.6 [IQR 59.1-60.0] vs 56.5 [IQR 54.1-58.9], P = .02). CONCLUSIONS: Among subjects with severe ARDS due to COVID-19, there was no difference in 28-d VFDs between prolonged and standard PP strategy. However, prolonged PP was associated with a longer ICU stay, increased use of neuromuscular blockers, and greater muscular impairment. This suggests that prolonged PP is not superior to the current recommended standard of care.

Shock Index and Physiological Stress Index for reestratifying patients with intermediate-high risk pulmonary embolism.

OBJECTIVE: Study and Evaluation of Two Scores: Shock Index (SI) and Physiological Stress Index (PSI) as discriminators for proactive treatment (reperfusion before decompensated shock) in a population of intermediate-high risk pulmonary embolism (PE). DESIGN: Using a database from a retrospective cohort with clinical variables and the outcome variable of "proactive treatment", a comparison of the populations was conducted. Optimal cut-off for "proactive treatment" points were obtained according to the SI and PSI. Comparisons were carried out based on the cut-off points of both indices. SETTING: Patients admitted to a mixed ICU for PE. PARTICIPANTS: Patients >18 years old admitted to the ICU with intermediate-high risk PE recruited from January 2015 to October 2022. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Population comparison and metrics regarding predictive capacity when determining proactive treatment. RESULTS: SI and PSI independently have a substandard predictive capacity for discriminating patients who may benefit from an early reperfusion therapy. However, their combined use improves detection of sicker intermediate-high risk PE patients (Sensitivity = 0.66) in whom an early reperfusion therapy may improve outcomes (Specificity = 0.9). CONCLUSIONS: The use of the SI and PSI in patients with intermediate-high risk PE could be useful for selecting patients who would benefit from proactive treatment.

Postoperative Blood Pressure Deficit and Acute Kidney Injury After Liver Transplant.

OBJECTIVES: Acute kidney injury is a common cause of morbidity in liver transplant recipients. In critically ill patients who received an orthotopic liver transplant, we examined whether those with acute kidney injury had a greater deficit between pretransplant and posttransplant hemodynamic pressure-related parameters compared with those without acute kidney injury in the early postoperative period. MATERIALS AND METHODS: We included patients who underwent an orthotopic liver transplant during the study period. We obtained premorbid and intensive care unit time-weighted average values for hemodynamic pressure-related parameters (systolic, diastolic, and mean arterial pressure; central venous pressure; mean perfusion pressure; and diastolic perfusion pressure) and calculated deficits in those values. We defined acute kidney injury progression as an increase of ≥1 Kidney Disease: Improving Global Outcomes stage. RESULTS: We included 150 eligible transplantrecipients, with 88 (59%) having acute kidney injury progression. Acute kidney injury was associated with worse clinical outcomes. All achieved pressure-related values were similar between transplant recipients with or without acute kidney injury progression. However, those with acute kidney injury versus those without progression had greater diastolic perfusion pressure deficit at 12 hours (-8.33% vs 1.93%; P = .037) and 24 hours (-7.38% vs 5.11%; P = .002) and increased central venous pressure at 24 hours (46.13% vs 15%; P = .043) and 48 hours (40% vs 20.87%; P = .039). CONCLUSIONS: Patients with acute kidney injury progression had a greater diastolic perfusion pressure deficit and increased central venous pressure compared with patients without progression. Such deficits might be modifiable risk factors for the prevention of acute kidney injury progression.

Combination of arterial lactate levels and Cv-aCO2/Da-vO2 ratio to predict early allograft dysfunction after liver transplantation.

PURPOSE: We examined the ability of the P(v-a)CO2/Da-vO2 ratio combined with elevated lactate levels to predict early allograft dysfunction (EAD). MATERIALS AND METHODS: Patients were classified into four groups according to lactate levels and P(v-a)CO2/Da-vO2 ratio: Group 1; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; Group 2; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0; group 3; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; group 4; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0. We defined EAD according to Olthoff criteria. RESULTS: One-hundred and fifty patients were included. EAD occurred in 41 patients (27.3%), and was associated with worse graft survival at 1 year (92% vs. 73%; P = ,003) as well as a higher re-transplantation rate (4,6% vs. 17,1%; P = ,019). The multivariate analysis revealed that P(v-a)CO2/Da-vO2 ratio at T6 [OR 7.05(CI95% 2.77-19.01, P<.001)] was an independent predictor for EAD. Belonging to group 1 at 6 h was associated with worse clinical outcomes but no association was found with 1-year graft survival or 1-year patient survival. CONCLUSIONS: In this single center, prospective, observational study in patients who received an OLT, we found that elevated lactate levels combined with a high Cv-aCO2/Da-vO2 after 6 h was associated with the development of EAD and worse clinical outcomes in the early postoperative period.

[Emergency treatment for traumatic cardiac arrest: prognostic factors and hospital outcome]. / Factores pronóstico y resultados intrahospitalarios de la parada cardiaca traumática atendida en un servicio de urgencias.

OBJECTIVES: To identify prehospital and on-arrival factors associated with hospital outcome in patients with traumatic cardiac arrest (TCA) discharged with recovered spontaneous circulation from the emergency department. MATERIAL AND METHODS: Multipurpose prospective cohort study of patients with TCA who recovered after treatment at a tertiary care hospital emergency department between 2003 and 2016. We gathered data on epidemiologic variables, type and cause of injuries, and prehospital and hospital emergency care. The outcome was overall hospital mortality. RESULTS: A total of 130 TCA cases were included; 123 patients (94.6%) had received blunt trauma injuries and 65 (50%) had been in traffic accidents. The mean (SD) age was 39 (16) years, and 96 (73.8%) were male. Fifty patients (65%) were in asystole and 42 (32.3%) had pulseless electrical activity. Sixteen (12.3%) survived to be discharged; 13 of the survivors (81.3%) had recovered neurological activity. Factors that were independently associated with hospital mortality were asystole on arrival of first responders (odds ratio [OR], 25; 95% CI, 2.5-247; P=.006), nonreactive pupils on arrival at the hospital (OR, 13; 95% CI, 2.0-79; P=.006), and an Injury Severity Score over 25 (OR, 13; 95% CI, 1.8-94; P=.011). CONCLUSION: Twelve percent of patients in this cohort survived to discharge after TCA and 8 out of 10 of the surviving patients recovered neurologically. Asystole at start of prehospital care, nonreactive pupils on hospital arrival, and a severity score over 25 may indicate poor prognosis after TCA.

OBJETIVO: Identificar los factores pronóstico a la llegada a urgencias y los resultados al alta hospitalaria de los pacientes en parada cardiaca traumática (PCT), documentada por un servicio de emergencias médicas (SEM), con posterior recuperación de la circulación espontánea (RCE). METODO: Estudio de cohorte multipropósito de pacientes con PCT recuperada atendidos en un servicio de urgencias (SU) de un hospital universitario de tercer nivel de 2003 a 2016. Se recogieron variables epidemiológicas, tipo y mecanismo del traumatismo, datos de la atención extrahospitalaria y del SU. La variable de resultado fue la mortalidad global intrahospitalaria. RESULTADOS: Se incluyeron 130 PCT, de los cuales 123 (94,6%) sufrieron un traumatismo cerrado y 65 (50%) tuvieron un accidente de tráfico. La edad media fue de 39 (DE 16) años y 96 (73,8%) fueron varones. Cincuenta pacientes (65%) presentaron asistolia y 42 (32,3%) actividad eléctrica sin pulso (AESP). Dieciséis (12,3%) sobrevivieron al alta, de los cuales 13 (81,3%) tuvieron recuperación neurológica favorable. Un ritmo de asistolia en la primera atención de extrahospitalaria (OR = 25; IC 95% 2,5-247; p = 0,006), las pupilas arreactivas a la llegada al hospital (OR = 13; IC 95% 2,0-79; p = 0,006), y una puntuación > 25 de la Injury Severity Score (ISS) (OR = 13; IC 95% 1,8-94; p = 0,011) se asociaron de forma independiente con la mortalidad intrahospitalaria. CONCLUSIONES: En nuestra serie, la supervivencia intrahospitalaria de la PCT fue un 12% siendo la recuperación neurológica favorable en ocho de cada diez vivos. El ritmo inicial en asistolia en la atención extrahospitalaria, la pupilas arreactivas a la llegada al hospital y una puntuación > 25 de ISS podrían implicar un mal pronóstico.

Factores pronóstico y resultados intrahospitalarios de la parada cardiaca traumática atendida en un servicio de urgencias / Emergency treatment for traumatic cardiac arrest: prognostic factors and hospital outcome

Objetivo: Identificar los factores pronóstico a la llegada a urgencias y los resultados al alta hospitalaria de los pacientes en parada cardiaca traumática (PCT), documentada por un servicio de emergencias médicas (SEM), con posterior recuperación de la circulación espontánea (RCE). Métodos: Estudio de cohorte multipropósito de pacientes con PCT recuperada atendidos en un servicio de urgencias (SU) de un hospital universitario de tercer nivel de 2003 a 2016. Se recogieron variables epidemiológicas, tipo y mecanismo del traumatismo, datos de la atención extrahospitalaria y del SU. La variable de resultado fue la mortalidad global intrahospitalaria. Resultados: Se incluyeron 130 PCT, de los cuales 123 (94,6%) sufrieron un traumatismo cerrado y 65 (50%) tuvieron un accidente de tráfico. La edad media fue de 39 (DE 16) años y 96 (73,8%) fueron varones. Cincuenta pacientes (65%) presentaron asistolia y 42 (32,3%) actividad eléctrica sin pulso (AESP). Dieciséis (12,3%) sobrevivieron al alta, de los cuales 13 (81,3%) tuvieron recuperación neurológica favorable. Un ritmo de asistolia en la primera atención de extrahospitalaria (OR = 25; IC 95% 2,5-247; p = 0,006), las pupilas arreactivas a la llegada al hospital (OR = 13; IC 95% 2,0-79; p = 0,006), y una puntuación > 25 de la Injury Severity Score (ISS) (OR = 13; IC 95% 1,8-94; p = 0,011) se asociaron de forma independiente con la mortalidad intrahospitalaria. Conclusión: En nuestra serie, la supervivencia intrahospitalaria de la PCT fue un 12% siendo la recuperación neurológica favorable en ocho de cada diez vivos. El ritmo inicial en asistolia en la atención extrahospitalaria, la pupilas arreactivas a la llegada al hospital y una puntuación > 25 de ISS podrían implicar un mal pronóstico (AU)

Objective: To identify prehospital and on-arrival factors associated with hospital outcome in patients with traumatic cardiac arrest (TCA) discharged with recovered spontaneous circulation from the emergency department. Material and methods: Multipurpose prospective cohort study of patients with TCA who recovered after treatment at a tertiary care hospital emergency department between 2003 and 2016. We gathered data on epidemiologic variables, type and cause of injuries, and prehospital and hospital emergency care. The outcome was overall hospital mortality. Results: A total of 130 TCA cases were included; 123 patients (94.6%) had received blunt trauma injuries and 65 (50%) had been in traffic accidents. The mean (SD) age was 39 (16) years, and 96 (73.8%) were male. Fifty patients (65%) were in asystole and 42 (32.3%) had pulseless electrical activity. Sixteen (12.3%) survived to be discharged; 13 of the survivors (81.3%) had recovered neurological activity. Factors that were independently associated with hospital mortality were asystole on arrival of first responders (odds ratio [OR], 25; 95% CI, 2.5-247; P=.006), nonreactive pupils on arrival at the hospital (OR, 13; 95% CI, 2.0-79; P=.006), and an Injury Severity Score over 25 (OR, 13; 95% CI, 1.8-94; P=.011). Conclusions: Twelve percent of patients in this cohort survived to discharge after TCA and 8 out of 10 of the surviving patients recovered neurologically. Asystole at start of prehospital care, nonreactive pupils on hospital arrival, and a severity score over 25 may indicate poor prognosis after TCA (AU)

Veno-arterial ECMO for rescue of severe airway hemorrhage with rigid bronchoscopy after pulmonary artery thromboendarterectomy.

Pulmonary endarterectomy (PEA) is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We present a patient with airway obstruction and acute respiratory failure due to large blood clots obstructing the trachea and main left bronchus. This condition was accompanied by right ventricle failure and cardiogenic shock. A venoarterial ECMO system was used for cardiopulmonary support before extracting the clots and clearing the airway by rigid bronchoscopy.

Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.