Limitation of life support techniques at admission to the intensive care unit: a multicenter prospective cohort study.

PURPOSE: To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission. METHODS: This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals' characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients' characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models. RESULTS: We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0-8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59-2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7-44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission. CONCLUSIONS: The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for ≥ 30 days.

Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial.

PURPOSE: To evaluate the efficacy of transpyloric feeding (TPF) compared with gastric feeding (GF) with regard to the incidence of ventilator-associated pneumonia in severe traumatic brain injury patients (TBI). DESIGN AND SETTING: Prospective, open-label, randomized study in an intensive care unit of a university hospital. PATIENTS: One hundred and four CHI adult patients admitted for TBI between April 2007 and December 2008. Patients were included within the first 24 h after ICU admission and were followed until discharge or 30 days after admission. INTERVENTION: Patients were randomized to TPF or GF groups. They received the same diet, with 25 kcal kg(-1) day(-1) of calculated energy requirements and a nitrogen intake of 0.2 g N kg(-1) day(-1). Primary outcome was the incidence of early and ventilatory-associated pneumonia. Secondary outcomes were enteral nutrition-related gastrointestinal complications (GIC), days on mechanical ventilation, length of ICU stay and hospital stay, and sequential organ failure assessment score (SOFA). RESULTS: The TPF group had a lower incidence of pneumonia, OR 0.3 (95% CI 0.1-0.7, P = 0.01). There were no significant differences in other nosocomial infections. The TPF group received higher amounts of diet compared to the GF group (92 vs. 84%, P < 0.01) and had lesser incidence of increased gastric residuals, OR 0.2 (95% CI 0.04-0.6, P = 0.003). CONCLUSIONS: Enteral nutrition delivered through the transpyloric route reduces the incidence of overall and late pneumonia and improves nutritional efficacy in severe TBI patients.

[Use of non-invasive ventilation in acute respiratory failure. Multicenter study in intensive care units]. / Utilización de la ventilación no invasiva en la insuficiencia respiratoria aguda. Estudio multicéntrico en unidades de cuidados intensivos.

OBJECTIVES: Study the use of non-invasive ventilation (NIV) in patients with acute respiratory failure in intensive care units (ICUs) in Spain. METHODS: A questionnaire was sent to 254 ICUs, after which, they were invited to participate in a multicenter, retrospective study, providing detailed information on ventilated patients. RESULTS: Answers were received from 123 hospitals. Of these, 119 used NIV, although its use varied greatly. NIV is the treatment of choice in 89% of the units for chronic obstructive pulmonary disease (COPD), in 79% for acute pulmonary edema (APE), in 53% for postextubation failure, in 53% for pneumonia 53%, and in 17% for acute respiratory distress syndrome (ARDS). It was used occasionally in COPD in 11% of the units, and in 21% of the units for APE. Eighteen hospitals provided additional information on 432 ventilated patients, 232 (54%) of whom received NIV as first line therapy. Presence of pneumonia or acute respiratory distress syndrome (ARDS) was an independent predictive factor of NIV failure (ORa=5.71; CI 95%, 1.83-17.8; p=0.003). Admission in a unit with experience in NIV in >50 patients/year (ORa=0.22; CI 95%, 0.07-0.63; p=0.005) and a higher PaO2/FiO2 ratio after one hour of ventilation (ORa=0.98 per point; CI 95%, 0.97-0.99; p<0.001) were protector factors. CONCLUSIONS: In Spain, NIV is widely used but it may continue to be underused in COPD and APE. The diagnosis of pneumonia or ARDS was an independent predictive risk factor. Admission in an ICU with NIV in more than 50 patients/year also have higher PaO2/FiO2 ratio after one hour of ventilation were predictive factors of success.

[Preliminary experience in an intensive care unit with Impella Recover. A new circulatory support system in patients with low cardiac output]. / Experiencia preliminar en una unidad de cuidados intensivos con Impella Recover. Asistencia ventricular microaxial en pacientes con bajo gasto cardíaco.

The low cardiac output syndrome following cardiopulmonary bypass is characterized by poor left ventricular contractibility that requires the support of high doses of vasoactive drugs, intra-aortic balloon pump, and sometimes makes it impossible to disconnect the extracorporeal circulation. We report 5 cases in which a "recently created" device in left ventricular support was inserted, the Impella Recover (Impella CardioSystems AG, Aachen, Germany) due to cardiogenic shock at the end of the surgery. Four of these patients recovered their heart function and the ventricular support could be removed after 70+/-55 h. In a fifth patient, the right ventricular failure warranted the use of Berlin Heart assist device.

Experiencia preliminar en una unidad de cuidados intensivos con Impella Recover®. Asistencia ventricular microaxial en pacientes con bajo gasto cardíaco / Preliminary experience in an intensive care unit with Impella Recover®. A new circulatory support system in patients with low cardiac output

El síndrome de bajo gasto cardíaco tras cardiotomía se caracteriza por una mala contractilidad ventricular izquierda que requiere el apoyo de altas dosis de fármacos vasoactivos, el uso de balón de contrapulsación y en ocasiones imposibilita la desconexión de la circulación extracorpórea. Presentamos 5 casos en los que se implantó un dispositivo de «reciente creación» en la asistencia ventricular izquierda: Impella Recover® (Impella CardioSystems AG, Aachen, Alemania), por shock cardiogénico al final de la intervención. De estos pacientes, 4 recuperaron la función cardíaca y la asistencia ventricular se pudo retirar tras un promedio de 70 ± 55h. En el quinto paciente, el dispositivo no mostró un resultado favorable y se evidenció insuficiencia ventricular derecha, por lo que fue necesario recurrir a una asistencia biventricular tipo Berlin Heart (AU)

The low cardiac output syndrome following cardiopulmonary bypass is characterized by poor left ventricular contractibility that requires the support of high doses of vasoactive drugs, intra-aortic balloon pump, and sometimes makes it impossible to disconnect the extracorporeal circulation. We report 5 cases in which a «recently created» device in left ventricular support was inserted, the Impella Recover® (Impella CardioSystems AG, Aachen, Germany) due to cardiogenic shock at the end of the surgery. Four of these patients recovered their heart function and the ventricular support could be removed after 70 ± 55h. In a fifth patient, the right ventricular failure warranted the use of Berlin Heart assist device (AU)

Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure.

BACKGROUND: Although conventional pressure ventilation (PSV) decreases the rate of intubation in acute respiratory failure, patient-ventilator dyssynchrony is a frequent cause of failure. In proportional assist ventilation (PAV), pressure is applied by the ventilator in proportion to the patient-generated volume and flow; therefore, there is automatic synchrony between the patient's effort and the ventilatory cycle. OBJECTIVE: The aim of this study was to compare the effects of PSV and PAV during noninvasive ventilation in the treatment of acute respiratory failure. DESIGN: Prospective randomised study. SETTING: A multidisciplinary 24-bed intensive care unit of an acute-care teaching hospital in Alicante, Spain. PATIENTS. This study included 117 consecutive adult patients with acute respiratory failure randomised to noninvasive ventilation delivered by PSV ( n = 59) or PAV ( n = 58). MEASUREMENTS AND RESULTS: There were no statistically significant differences between patients assigned to each mode of ventilation with regard to baseline parameters and aetiological diagnoses of acute respiratory failure. With regard to outcome data, no significant differences were observed between PSV and PAV in the frequency of intubation (37% vs 34%), mortality rate (29% vs 28%), and mean length of stay. Subjective comfort (0-10 visual analogue scale) was rated higher and intolerance occurred less frequently (3.4% vs 15%, P = 0.03) in the PAV than in the PSV mode. CONCLUSIONS: Although PAV seems more comfortable and intolerance occurred less frequently, no major differences exist in terms of physiological improvement or in terms of outcomes when comparing PSV and PAV.