Factores clínico-radiológicos asociados con muerte encefálica precoz / Clinico-radiological related to early brain death factors

Objective: To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h. Design A retrospective cohort study was made covering the period 2015−2017. Setting An adult Intensive Care Unit (ICU).Patients/methodsEpidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. Results A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.ConclusionsEarly BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation (AU)

Objetivo: Identificar los factores clínico-radiológicos que se asocian a evolución precoz a muerte encefálica (ME), definida esta como la ocurrida en ≤24 horas Diseño Estudio de cohortes retrospectivo desde 2015 hasta 2017, ambos incluidos. Ámbito Servicio de Medicina Intensiva (SMI) de adultos.Pacientes y métodoAnálisis de variables clínico-epidemiológicas y de la TC craneal de ingreso en pacientes con evolución a ME. Resultados Se analizaron 166 ME, 86 varones, edad media 62,7 años, 42,8% hemorragia intracerebral, 18,7% HSA, 17,5% TCE, 7,8% ictus isquémico, 9% anoxia y 4,2% otras causas; 50% HTA, 34% dislipemia, 33% tabaquismo, 21% antiagregación, 19% enolismo. El 15% anticoagulación, 15% diabetes. El GCS fue tres en el 68,8% en ME precoz frente 38,2% en ME >24 h (p 0,0001); 85 hematoma supratentorial (90,9 mL en ME precoz vs. 82,7 mL ME tardía, p 0,54); 12 hematoma infratentorial. Desplazamiento medio de línea media 10,7 mm en ME precoz vs. 7,8 mm en ME tardía (p 0,045); 91 pacientes ventriculomegalia y 38 trasudado periependimario (p 0,021). Borramiento completo de cisternas basales 36 en ME precoz frente a 24 en ME tardía (p 0,005), borramiento de surcos (p 0,013), pérdida de diferenciación córtico-subcortical (p 0,0001) y ausencia de cisterna supraselar (p 0,005). La medición de la vaina del nervio óptico no mostró diferencias significativas entre los dos grupos.ConclusionesSe asoció con ME ≤ 24 horas el GCS < 5, el desplazamiento de línea media, la pérdida de diferenciación córtico-subcortical, el borramiento de surcos, el borramiento completo de cisternas basales, de la cisterna supraselar y la presencia de trasudado periependimario (AU)

Clinico-radiological related to early brain death factors.

OBJECTIVE: To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h. DESIGN: A retrospective cohort study was made covering the period 2015-2017. SETTING: An adult Intensive Care Unit (ICU). PATIENTS/METHODS: Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. RESULTS: A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. CONCLUSIONS: Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Clinico-radiological related to early brain death factors. / Factores clínico-radiológicos asociados con muerte encefálica precoz.

OBJECTIVE: To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours. DESIGN: A retrospective cohort study was made covering the period 2015-2017. SETTING: An adult Intensive Care Unit (ICU). PATIENTS/METHODS: Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. RESULTS: A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. CONCLUSIONS: Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Prospective multicentre study of rectal carriage of multidrug-resistant Enterobacteriaceae among health-care workers in Spain.

OBJECTIVES: To investigate the rectal carriage of multidrug-resistant Enterobacteriaceae (colistin-resistant, extended-spectrum ß-lactamase (ESBL) -producers and/or carbapenemase-producers) among health-care workers (HCWs) from six Spanish hospitals. METHODS: Rectal swabs from 258 HCWs, employed in intensive care units, haematology wards and clinical microbiology laboratories from six hospitals in northern Spain were studied. They were cultured in selective media for Gram-negative resistant bacteria. Detection of antimicrobial resistance genes and multilocus sequence typing were performed by PCR and further sequencing. A questionnaire including data related to risk factors of colonization/infection by resistant bacteria (age, gender, chronic diseases, immunosuppressive therapies, invasive procedures or antimicrobial treatments) was given to each participant. RESULTS: No carbapenemase-producing Enterobacteriaceae were recovered. However, 8/258 HCWs (3.1%) were positive for ESBL-producing isolates. This rate was not higher than the colonization rate previously reported in Spain for healthy people in the community. Five isolates showed high-level resistance to colistin (MICs ranging from 8 to 128 mg/L) but all of them were negative for the mcr genes tested. No statistically significant risk factors for gut colonization by ESBL-producing or colistin-resistant Enterobacteriaceae were identified among the HCWs participating in the study. CONCLUSIONS: Our data suggest that working in hospitals does not represent a risk for rectal carriage of multidrug-resistant Enterobacteriaceae.

Nosocomial ventriculitis caused by a meticillin- and linezolid-resistant clone of Staphylococcus epidermidis in neurosurgical patients.

BACKGROUND: Postneurosurgical ventriculitis is mainly caused by coagulase-negative staphylococci. The rate of linezolid-resistant Staphylococcus epidermidis (LRSE) is increasing worldwide. AIMS: To report clinical, epidemiological and microbiological data from a series of ventriculitis cases caused by LRSE in a Spanish hospital between 2013 and 2016. METHODS: Cases of LRSE ventriculitis were reviewed retrospectively in a Spanish hospital over a four-year period. Clinical/epidemiological data of the infected patients were reviewed, the isolates involved were typed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing, and the molecular bases of linezolid resistance were determined. FINDINGS: Five cases of LRSE ventriculitis were detected. The patients suffered from cerebral haemorrhage or head trauma that required the placement of an external ventricular drain; spent a relatively long time in the intensive care unit (ICU) (10-26 days); and three out of the five patients had previously been treated with linezolid. All LRSE had the same PFGE pattern, belonged to ST2, and shared an identical mechanism of linezolid resistance. Specifically, all had the G2576T mutation in the V domain of each of the six copies of the 23S rRNA gene, together with the Q136L and M156T mutations and the 71GGR72 insertion in the L3 and L4 ribosomal proteins, respectively. CONCLUSION: The high ratio of linezolid consumption in the ICU (7.72-8.10 defined daily dose/100 patient-days) could have selected this resistant clone, which has probably become endemic in the ICU where it could have colonized admitted patients. Infection control and antimicrobial stewardship interventions are essential to prevent the dissemination of this difficult-to-treat pathogen, and to preserve the therapeutic efficacy of linezolid.

Control de una endemia de Acinetobacter baumannii multirresistente en la UCI. Recordando lo obvio / Control of an Acinetobacter baumannii multidrug resistance endemic in the ICU. Recalling the obvious

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Infectious complications related to external ventricular shunt. Incidence and risk factors. / Complicaciones infecciosas relacionadas con el drenaje ventricular externo. Incidencia y factores de riesgo.

OBJECTIVE: Infectious complications related to external ventricular shunt (ICREVS) are a main problem in neurocritical intensive care units (ICU). The aim of the review is to assess the incidence of ICREVS and to analyse factors involved. METHODS: Retrospective analysis, adult polyvalent ICU in a third level reference hospital. Patients carrying external ventricular shunt (DVE) were included. Those patients with central nervous system infection diagnosed prior DVE placement were excluded. RESULTS: 87 patients were included with 106 DVE. Most common admittance diagnosis was subarachnoid haemorrhage (49.4%). 31 patients with 32 DVE developed an ICREVS. Infection rate is 19.5 per 1000 days of shunt for ICREVS and 14 per 1000 days for ventriculitis. 31.6% of the patients developed ICREVS and 25.3% ventriculitis. Patients who developed ICREVS presented higher shunt manipulations (2.0 ± 0.6 vs. 3.26 ± 1.02, p=0.02), shunt repositioning (0.1 ± 0.1 vs. 0.2 ± 0.1) and ICU and hospital stay (29.8 ± 4.9 vs 49.8 ± 5.2, p<0.01 y 67.4 ± 18.8 vs. 108.9 ± 30.2, p=0.02. Those DVE with ICREVS were placed for longer not only at infection diagnosis but also at removal (12.6 ± 2.1 vs. 18.3 ± 3.6 and 12.6 ± 2.1 vs. 30.4 ± 7.3 days, p<0.01). No difference in mortality was found. CONCLUSIONS: One out of three patients with a DVE develops an infection. The risk factors are the number of manipulations, repositioning and the permanency days. Patients with ICREVS had a longer ICU and hospital average stay without an increase in mortality.

[Epidemiological surveillance for multidrug-resistant microorganisms in a general ICU]. / Vigilancia epidemiológica para microorganismos multirresistentes en una UCI polivalente.

OBJECTIVE: Multidrug resistant (MDR) microorganisms represent a threat for patients admitted in Intensive Care Units (ICUs). The objective of the present study is to analyse the results of epidemiological surveillance cultures for these microorganisms in one of these units. METHODS: General ICU. Retrospective analysis, descriptive statistics. Analysis of epidemiological surveillance cultures for MDR microorganisms in 2015. Studied microorganisms: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-and/or carbapenemase-producing Klebsiella pneumoniae (CESBL-KP) and MDR Acinetobacter baumannii (MDRAB). RESULTS: One thousand, two hundred and fifty nine patients admitted. A total of 2,234 specimens from 384 patients were analysed (690, 634, 62 and 286 were rectal, throat, nasal and skin swabs respectively). Global APACHE II was 18.3 ± 8 versus 21.7 ± 7.8 in patients colonized/infected on admission. Global mortality was 19.7% versus 22.3% in patients colonized/infected on admission. The higher sensitivities achieved with the different samples for the different microorganism detection were as follows. MRSA: 79% and 90% for nasal and nasal + throat swabs, respectively. MDRAB: 80% and 95% for throat and throat + rectal swabs, respectively. CESBL-KP: 95% and 98% for rectal and rectal + throat swabs, respectively. 94 out of the 384 patients (24.4%) were colonized/infected with MDR at admission. 134 patients (10.6% of the total patients admitted) were colonized/infected with a total of 169 MMR during the hospital stay. MRSA has the earliest colonization/infection (9.2 ± 6.4days) and ESBL-producing Enterobacteriaceae, the latest (18.7± 16.4 days). CONCLUSIONS: 24.4% of patients were colonized/infected by MDR at admission. Nasal, throat and rectal swabs were the most effective specimens for recovering MRSA, MDRAB and CESBL-KP, respectively. The combination of two specimens improves MDR detection except for CESBL-KP. Skin swabs are worthless. The most prevalent MDR at admission were ESBL-producing Enterobacteriaceae while the most frequent hospital acquired MDR was MDRAB..

Utilidad del estudio metabólico cerebral con PET/TC 18F-fluorodeoxiglucosa para descartar estado vegetativo / The role of 18-F-fluorodeoxyglucose PET/CT in ruling out vegetative state

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Es tiempo de cambiar la política de visitas en la UCI / It is time to change the visiting policy in intensive care units

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Abrir las puertas de la UCI. Una necesidad inexcusable / Open de doors on the ICU. An unavoidable necessity

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Política de visitas, diseño y confortabilidad en las unidades de cuidados intensivos españolas / Visitation policy, design and comfort in Spanish intensive care units

Objetivo. Conocer el diseño y confortabilidad de las unidades de cuidados intensivos (UCI). Analizar el horario de visitas, la información y la participación familiar en los cuidados del paciente. Diseño. Estudio multicéntrico, descriptivo. Ámbito. Unidades de cuidados intensivos de España. Método. Cuestionario enviado por correo electrónico a los socios de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), suscriptores de la Revista Electrónica de Medicina Intensiva y difundido por el blog Proyecto HU-CI. Resultados. Se analizaron 135 encuestas pertenecientes a 131 hospitales. Horario de visitas: 3,8% tienen horario abierto 24 h, 9,8% horario abierto diurno y 67,7% tienen 2 visitas/día. Información: la realiza solamente el médico en el 75,2%, médico y enfermera juntos 4,5% con una frecuencia de una vez/día en el 79,7%. Los fines de semana se informa en el 95,5%. Información telefónica 74,4%. Participación familiar en los cuidados del paciente: higiene 11%, administración de comida 80,5% y fisioterapia 17%. Objetos personales permitidos: teléfono móvil 41%, ordenador 55%, equipo de música 77%, televisión 30%. Arquitectura y confortabilidad: todos los boxes individuales 60,2%, luz natural 54,9%, televisión 7,5%, música ambiental 12%, reloj en el box 15,8%, medidor de ruido ambiental 3,8% y sala de espera cercana a UCI 68,4%. Conclusiones. La política de visitas es restrictiva, predominando una cultura de UCI cerrada. Generalmente no se permiten medios de comunicación tecnológicos. Hay poca incorporación de la familia en los cuidados del paciente. El diseño de la UCI no garantiza la privacidad ni proporciona la confortabilidad deseable (AU)

Objective. To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care. Design. Descriptive, multicentre study. Setting. Spanish ICUs. Methods. A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI. Results. A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24 h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%. Conclusions. Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort (AU)

[Visitation policy, design and comfort in Spanish intensive care units]. / Política de visitas, diseño y confortabilidad en las unidades de cuidados intensivos españolas.

OBJECTIVE: To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care. DESIGN: Descriptive, multicentre study. SETTING: Spanish ICUs. METHODS: A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI. RESULTS: A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%. CONCLUSIONS: Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort.

Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo / Endovascular treatment and intra-arterial thrombolysis in acute ischemic stroke

Objetivo: Analizar la eficacia y la seguridad de la trombólisis intraarterial y el tratamiento endovascular en pacientes con ictus isquémico agudo. Diseño y ámbito: Estudio prospectivo observacional en una unidad de cuidados intensivos. Pacientes: Dieciséis pacientes recibieron tratamiento endovascular. Se recogieron datos epidemiológicos, localización de la oclusión arterial, tiempo desde el ictus al tratamiento, indicación del tratamiento, National Institutes of Health Stroke Scale al ingreso y al alta hospitalaria, y complicaciones y evolución funcional por escala de Rankin modificada realizada mediante una encuesta telefónica. Resultados: Diez varones, con una edad media de 59 años (29-74) y una estancia media en la unidad de cuidados intensivos de 6 días (1-33). Siete pacientes requirieron ventilación mecánica. Indicación del tratamiento: 4 casos por fracaso de la trombólisis intravenosa, 5 por oclusión de gran vaso, 2 por estar fuera de la ventana terapéutica, 3 por oclusión de la circulación posterior, uno por estar fuera de la ventana terapéutica y tener, además, una oclusión de gran vaso y uno por contraindicación para la trombólisis intravenosa. Localización de la oclusión: 3 en la circulación posterior y 13 en el territorio carotídeo y sus ramas. El fibrinolítico utilizado fue uroquinasa en dosis de 100.000-600.000 UI. Cuatro pacientes requirieron embolectomía mecánica y 10, implantación de stent. Se obtuvo recanalización completa en 11 pacientes (69%) y parcial en 4 (25%). Tres pacientes evolucionaron a muerte encefálica. Seis pacientes (46%) tuvieron una buena recuperación (escala de Rankin modificada <2). Como complicación técnica destacó un seudoaneurisma de la arteria femoral. Conclusiones: El tratamiento intraarterial obtiene altas tasas de recanalización y buenos resultados funcionales con escasas complicaciones. Su uso estaría indicado en pacientes con afectación neurológica importante (National Institutes of Health Stroke Scale >10) -tiempo de evolución de 3-6h-, y contraindicacio'n para la trombólisis intravenosa y la oclusión arterial proximal (AU)

Objective: Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. Design and area: An observational prospective study in the Intensive Care Unit. Patients and methods: 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected. Results: Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score <2). Technical complication was 1 femoral artery pseudoaneurysm. Conclusions: With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS >10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion (AU)